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ORAL  SURGERY 


ORAL    SURGERY 

—r 

A  TEXT-BOOK  ON  GENERAL  SURGERY  AND 
MEDICINE    AS  APPLIED  TO   DENTISTRY 


BY 

STEWART  LEROY  McCURDY 

PROFESSOR    OF    ANATOMY    AND    ORAL    SURGERY,    SCHOOL   OF    DEijTlSTRY,    UNIVERSITY   OF    PITTSBURGH; 

CHAIRMAN   OF   SECTION   ON    STOMATOLOGY,    AMERICAN    MEDICAL    ASSOCIATION    (1910,  1911,  1912); 

ORTHOPEDIC   SURGEON,  PRESBYTERIAN    AND    COLUMBIA    HOSPITALS,  ETC.,  PITTSBURGH. 

AUTHOR   OF  "manual  OF  ORTHOPEDIC  SURGERY,"    "aNATOMY  IN  ABSTRACT," 

"emergencies    in    ABSTRACT,"    "aRTHROSTEOPEDIC    SURGERY." 


WITH   TWO  HUNDRED  AND   TWENTY-EIGHT  ILLUSTRATIONS 


NEW  YORK  AND  LONDON 

D.   APPLETON    AND    COMPANY 

1912 


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Copyright,  1912,  by 
D.  APPLETON    AND    COMPANY 


PRINTED    IN 
NEW  YORK,  U.  S.  A. 


TO 

JAMES  FAIRCHILD  BALDWIN,  A.M.,  M.D. 

COLUMBUS,  OHIO 

THE   UNCONSCIOUS   MONITOR   OF   MY   PROFESSIONAL   CAREER 
THIS   BOOK   IS   DEDICATED    BY   THE   AUTHOR 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/oralsurgerytextbOOmccu 


NOTE 

The  present  volume  is  the  first  of  a  series  of  text-books  which 
has  been  i^lannecl  by  the  Commission  on  Text -books  of  the  Institute 
of  Dental  Pedagogics.  It  is  intended  that  the  entire  subject  of 
dentistry  as  it  should  be  presented  in  a  standard  dental  college  shall 
be  covered  in  a  definite  number  of  books,  each  book  including  only 
such  subjects  as  properly  belong  to  it.  It  appeared  advisable,  however, 
to  most  briefly  consider  the  subjects  of  bacteriology  and  inflammation 
and  their  immediate  results  to  properly  introduce  the  subjects  which 
follow  and  which  constitute  the  main  part  of  this  book.  Some  of 
the  chapters  in  this  book  would  be  made  more  explicit  if  the  regional 
or  special  anatomy  of  the  part  under  discussion  were  briefly  given, 
but  the  student  is  referred  to  the  text-book  on  general  anatomy, 
which  will  include  special  and  regional  anatomy  of  the  face,  mouth 
and  head. 


y^^^cH.^^^ 


PREFACE 

Oral  Suegert  is  a  ■well-defined  and  separate  specialty.  Whether 
it  belongs  to  general  surgery  or  to  dentistry,  or  whether  the  dental 
student  needs  more  oral  surgery  and  more  knowledge  of  general 
medicine  and  surgery  or  whether  the  medical  student  and  practi- 
tioner needs  more  dentistry  by  way  of  the  oral  surgical  route,  is  a 
question.  Garretson's  "Oral  Surgery,"  which  was  the  first  systematic 
work  on  this  subject,  included  ererything  in  dentistry  and  much  on 
general  medicine  and  surgery.  This,  however,  is  not  the  modern 
idea  of  the  scope  of  the  subject.  The  present  book  is  divided  into 
two  parts,  the  first  part,  including  the  principles  of  general  medicine 
and  surger}',  intended  for  the  Junior  student,  and  the  second  part, 
for  the  Senior  student,  including  oral  surgery  proper.  The  aim  has 
been  to  eliminate  everything  that  cannot  be  directly  associated  with 
the  practice  of  dentistry  or  be  of  special  interest  to  the  dental  student 
and  practitioner.  Dental  pathology  does  not  differ  from  general  pa- 
thology, and  the  student  who  has  been  trained  in  the  principles  in 
general  is  better  prepared  to  appreciate  the  pathological  changes  as 
they  appear  in  the  mouth. 

The  author  is  indebted  to  the  "'American  Practice  of  Surgery," 
Keen's  "Surgery,"  Bryant's  "Operative  Surgery,"  and  current  dental 
and  medical  literature  in  the  preparation  of  the  following  pages,  and 
it  has  been  the  aim  to  give  credit  when  extracts  or  abstracts  have 
been  made  by  using  quotation  marks.  The  author  especially  desires 
to  acknowledge  the  valuable  assistance  given  in  the  preparation  of 
the  manuscript  to  the  following :  A.  B.  "Wallgren,  M.D.,  Bacteriology 
and  Inflammation;  George  C.  Johnston,  M.D.,  X-ray;  G.  A.  Holli- 
day,  M.D.,  Venereal  Diseases;  and  H.  B.  Kohberger,  M.D..  General 
Diagnosis  and  Vascular  Diseases. 

Stewart  LeEot  McCurdy. 
Pittsburgh,  Pa. 


IX 


CONTENTS 

PART  I 
PEINCIPLES    OF   SURGERY 

CHAPTER  I 

PAGES 

BACTERIA     AND     INFLAMMATION     AND     THEIR     IMMEDIATE     RESULTS 

Bacteria — Inflammation — Necrosis — Gangrene — Suppurative     in- 
flammation         .     .         3-15 

CHAPTER    II 

NON-SPECIFIC     INFECTIONS 

Cellulitis — Sapremia — Septicemia — Pyemia 16-22 

CHAPTER    III 

SPECIFIC    INFECTIONS 

Erysipelas — Actinomycosis — Tetanus — Hydrophobia — Anthrax      .       23-31 

CHAPTER    IV 

GENERAL    TUBERCULOSIS 

Etiology — Pathology — Treatment        32-34 

CHAPTER    V 

THE    VENEREAL    DISEASES 

Gonorrhea — Chancroid — Syphilis        35-53 

CHAPTER   VI 

WOUNDS    AND    HEMORRHAGE 

Wounds — Hemorrhage — Burns  and  scalds — Injuries  to  brain  and 

skull — Foreign  bodies 54-65 

xi 


xii  CONTENTS 

PAGES 

CHAPTER   VII 

BANDAGING 

Uses  of  bandages — Varieties  of  bandages 66-6C 

CHAPTER   VIII 

SHOCK    AND    MEDICAL    EMERGENCIES 

Shock — Unconscious  conditions 70-74 

CHAPTER  IX 

ASEPSIS     AND    ANTISEPSIS 

Germicides — Sterilization     of     dressings     and    instruments — The 

operating  room — The  patient — Sutures  and  ligatures  .     .     .       75-79 

CHAPTER    X 

GENERAL    DIAGNOSIS 

Case  history — How  to  obtain  a  complete  knowledge  of  a  disease — 

Diagnostic    signs 80-87 

CHAPTER    XI 

DISEASES    AND    INJURIES    OF    THE    VASCULAR    SYSTEMS 

The  Heart — Diseases   and  injuries   of  the   arteries   and   veins — 

Lymphatics •     •       88-97 


PART    II 

ORAL   SURGERY 

CHAPTER    XII 

GENERAL    INTRODUCTION 

Disturbances  due  to   dentition — Oral  hygiene — Complications  of 

extraction — Reflex  neuroses  from  the  teeth 101-111 


CONTENTS  xiii 

PAGES 

CHAPTER   XIII 

ALVEOLAR    ABSCESS    AND    ITS    MORE    GRAVE    CONSEQUENCES 

Pathology — Alveolar  abscess  of  the  maxilla — Treatment  ....  112-122 

CHAPTER    XIV 

MOUTH    LESIONS 

Local  acute  stomatitis — Symptomatic  mouth  lesions — Some  affec- 
tions of  the  nasal  and  oral  cavities  which  are  related  to  skin 
diseases — Vincent's  angina 123-145 

CHAPTER    XV 

DISEASES    OF    THE    TONGUE 

Congenital  defects — Acquired  affections 146-159 

CHAPTER    XVI 

SURGICAL   DISEASES    AND    INJURIES    OF    THE   FACE 

Diseases  of  the  sebaceous  glands — Parasitic  diseases  of  the  skin — 
Acute  infection  of  the  skin — Wounds  of  the  face  and  mouth 
—Neuroses  of  the  face 160-170 

CHAPTER   XVII 

GENERAL    BONE    DISEASES 

Osteomyelitis — Periostitis 171-178 

CHAPTER   XVIII 

DISEASES    OF   THE   MANDIBLE 

Alveolar  necrosis — Periostitis  of  the  body  of  the  mandible — 
Osteomyelitis  of  the  body  of  the  mandible — Chemical 
necrosis — Exanthematous  necrosis 179-192 

CHAPTER    XIX 

DISEASES  OF  THE   MAXILLA 

Acute  suppurative  diseases — Tuberculous  diseases — Diseases  of 
the  bones  due  to  lesions  in  the  central  nervous  system — Re- 
generation of  bone — Technique  of  operations  upon  bones  of 
the  faoe 193-208 


xiv  CONTENTS 

PAGES 

CHAPTER    XX 

TUBERCULOSIS    OF    THE    FACE^     MOUTH    AND    JAW 

Tuberculosis    of   the   face — Tuberculosis    of    the    mouth — Tuber- 
culosis of  the  facial  bones 209-218 

CHAPTER  XXI 

SYPHILIS    OF   THE    MOUTH 

The  initial  lesion — Secondary  manifestations — Tertiary  lesions.     .   219-237 

CHAPTER   XXII 

TUIMORS    IN"    GEK-EEAL 

Classification — Fibroma — Lipoma — Adenoma — Neuroma — Cysts — 

Non-infective  tumors  of  the  soft  tissues  of  the  mouth  .     .     .  238-247 

CHAPTER   XXIII 

DEVELOP^IEMTAL    TUMORS    OF    THE    TEETH 

Epithelial  tumors — Eollicular  odontomata — Radicular  odontomata — 

Composite  odontomata — Symptoms — Diagnosis — Treatment  .  218-257 

CHAPTER   XXIV 

NEOPLASMS    OP    THE   AIA'EOLAR    SOFT   TISSUES    AND    BONE    TUMORS   AND    CYSTS 

Neoplasms  of  the  alveolar  soft  tissues — Bone  tumors  and  cysts  .   258-274 

CHAPTER   XXV 

MALIGNANT  TUMORS  OF  THE   MOUTH 

Sarcoma  in  general — Sarcoma  of  the  mouth — Carcinoma  in  gen- 
eral— Epithelioma  of  the  mouth 275-287 

CHAPTER   XXVI 

CYSTS    AND    TUMEFACTIONS    FROM    DEVELOPED    TEETH 

Impaction  of  teeth — Cysts  from   delayed   eruption — Cysts  from 

roots  of  developed  teeth 288-299 


CONTENTS  XV 

PAGES 

CHAPTER   XXVII 

CONGENITAL     AND     ACQUIRED     DEFORMITIES     OF     THE     FACE     AND     MOUTH     IN 

GENERAL 

Development    of    the    face    and    mouth — Median    facial    cleft — 

Other  congenital  defects — Acquired  deformities  in  general     .   300-309 

CHAPTER    XXVIII 

HARE   LIP 

Clinical  varieties — Prognosis — Operation  for  hare  lip 310-315 

CHAPTER   XXIX 

CLEFT  PALATE 

History — Etiology — Varieties — Time  of  operation — Anesthesia — 

Mouth  gags— Operations 316-333 

CHAPTER   XXX 

DISEASES    OF     THE     MAXILLARY     AND     OTHER     SINUSES 

Anatomy — Diseases  of  the   antrum 334-352 

CHAPTER   XXXI 

FACIAL     NEURALGIA 

Symptoms — Diagnosis — Prognosis — Treatment 353-363 

CHAPTER     XXXII 

THE    SALIVARY    GLANDS 

Diseases  of  the  salivary  glands 364-375 

CHAPTER    XXXIII 

ANKYLOSIS 

Temporary  ankylosis — Permanent  ankylosis 376-388 


xvi  CONTENTS 

PAGES 

CHAPTER  XXXIV 

FRACTURE    IN    GENERAL 

Varieties — Etiology — Symptoms — Diagnosis — Prognosis — Treat- 
ment       389-392 

CHAPTER   XXXV 

FRACTURE    OF    THE    MANDIBLE 

Frequency — Location — Causes — Symptoms — Diagnosis — Complica- 
tions— Repair — Treatment 393-407 

CHAPTER    XXXVI 

FRACTURE     OF     MAXILLA     AND     UPPER    PART    OF     FACE 

Fracture  of  the  maxilla — Fracture  of  nasal  bones — Fracture  of 

the  malar  bone — Fracture  of  the  zygomatic  arch 408-417 

CHAPTER    XXXVII 

DISLOCATIONS 

Dislocations  in  general — Dislocation  of  the  mandible  .....   418-424 
CHAPTER    XXXVIII 

X-RAY    IN    ORAL     SURGERY 

X-Ray  in  oral  surgery 425-432 

APPENDIX 
Questions  in   oral  surgery 435-456 

Index 459-469 


LIST   OF   ILLUSTRATIONS 

FIG.  PA.GE 

1.  Aetiuomvcosis 27 

2.  Initial  lesion  on  the  finger  of  a  dentist 42 

3.  Macular   sypliilide 45 

4.  Syphilitic  ulceration  of  the  face  and  nose  ........  46 

5.  Difl'used   syphilitic   periostitis   of   hereditary   origin   ....  50 

6.  Congenital  diffused  specific  periostitis,   suppurating  at  many 

points 52 

7.  Roller    bandages       .     . 67 

8.  Triangular    bandages .  68 

9.  Location   of   heart   sounds 89 

10.  Atrophy  marks  on  teeth 107 

11.  Case  of  alveolar  abscess 114 

12.  X-ray   of   alveolar   abscess IIS 

13.  Granulation   from   abscess   resembling   papilloma 119 

14.  The  most  common  alveolar  fistula  of  the  maxilla 120 

15.  Method  of  establishment  of  naso-oral  fistula 120 

16.  Abscess 121 

17.  Alveolar   abscess    of   the    mandible 121 

IS.     Ulcerative    stomatitis 128 

19.  Mycosic  stomatitis 130 

20.  Cancrum   oris 132 

21.  Strawbei'iy    tongue 137 

22.  Follicular  tonsillitis 137 

23.  Diphtheritic  throat 137 

24.  Koplik's  spots 137 

25.  Vincent's   angina    (Thomson) 143 

26.  Hypertrophy  of  the  tongue   (Bryant) 148 

27.  Ludwig's   angina 151 

28.  Ludwig's    angina 151 

29.  Leucoplakia    linguae 153 

30.  EjDithelioma  of  the  tongue 157 

31.  Acne  vulgaris 162 

32.  Blastomycosis 164 

33.  Tinea  sycosis 165 

34.  Periostitis   of    mandible 131 

35.  Periostitis 182 

xvii 


xviii  LIST    OF    ILLUSTRATIONS 


FIG. 


PAGE 


36.  Periostitis 183 

37.  Alveolar  process  in  osteomyelitis 184 

38.  Alveolar  process  in  osteomyelitis 185 

39.  Osteomyelitis  of  the  mandible 186 

40.  Arsenic   neci'osis 189 

41.  Schematic  outline  of  bone  removed 190 

42.  Eeproduction  on  mandible  of   bone   destroyed   ......  190 

43.  Suppurative  periostitis  of  the  mandible ,     .  191 

44.  Sequestrum  removed  from  maxilla 194 

45.  Method  of  closing  naso-oral  fistula .  195 

46.  Completed  operation  for  naso-oral  fistula .  195 

47.  Final   result   of   operation 196 

48.  Acromegaly 198 

49.  Sequestrum  representing  enlii-e  right  half  of  mandible  .     .     .  201 

50.  Articulation  of  teeth  after  removal  of  sequestrum  in  Fig.  49  .  202 

51.  Papilla  showing  necrosis  in  case  of  Fig.  50,  before  operation  .  203 

52.  External  appearance  in  complete   destruction  of  bone  .     .     .  204 

53.  Area  bone  destroyed 204 

54.  Teeth  together  after  regeneration   of  bone 205 

55.  Mouth   open  after  regeneration  of  bone 205 

56.  Entire  right  half  of  mandible  removed  in  four  fragments  .     .  206 

57.  Result   after  regeneration   of  bone 206 

58.  Cosmetic   result 207 

59.  Mouth  retractor 208 

60.  Tuberculosis   cutis 210 

61.  Lupus  vulgaris  in  early  stage 211 

62.  Periadenitis   mucosa  neerotica   recurrens   . 215 

63.  Periadenitis  mucosa  neerotica   recurrens 215 

64.  Tuberculosis  of  the  mouth 216 

65.  Chancre  of   lip 221 

66.  Chancre  of  tongue 222 

67.  Secondary  lesion  of  syphilis  with  salivation 226 

68.  Gumma  of  tongue ' 227 

69.  Sclerosing  glossitis 229 

70.  Acquired  cleft  palate  .... 232 

71.  Sequestrum 233 

72.  Appearance   of  mouth  after  treatment  for  syphilis  ....  233 

73.  Hereditary  necrosis 235 

74.  Cleft  palate  from  hereditary  syphilis 236 

75.  Odontomata,  or  enamel  deposit  on  a  developed  tooth  ....  251 

76.  Odontomata,  or  enamel  deposit  on  a  developed  tooth  ....  251 

77.  Odontoma 253 


LIST    OF    ILLUSTRATIONS  xix 


PAGE 


78.  Microscopic  section  of  odontoma 254 

79.  Multiple  cyst  of  mandible  caused  by  impaction  of  two  teeth  256 

80.  Papilloma  of  alveolus 259 

81.  Papilloma  of  alveolus 260 

82.  Papilloma  of  alveolus 261 

83.  Papilloma  of  alveolus 262 

84.  Polypus  of  gum 263 

85.  Polypus  of  gum 264 

86.  Hypertrophy  of  gum 265 

87.  Hypertrophy  of  gum 266 

88.  Myeloid    epulis 267 

■89.  Fibroid  epulis  before  operation 268 

90.  Fibroid    epulis    after    operation 269 

91.  Chloroma,   lower  jaw 269 

92.  Chloroma,  upper  jaw 270 

93.  Osteoma   of  maxilla 272 

94.  X-ray   of   osteoma 273 

95.  Sarcoma  of  mandible 279 

96.  Sarcoma  of  maxilla 280 

97.  Epithelioma  of  lip  before  X-ray 282 

98.  Epithelioma  of  lip  after  X-ray 282 

99.  Epithelioma  of  cheek 284 

100.  Epithelioma  of  mouth 285 

101.  Epithelioma  of  alveolus 286 

102.  Carcinoma   of  mandible 287 

103.  Aluminum  bridgework  as  substitute 287 

104.  Impacted   central 289 

105.  Impacted  lateral 290 

106.  Impacted   teeth 291 

107.  Impaction  of  teeth  with  abscesses  and  cysts 292 

108.  Impaction  of  teeth  with  abscesses  and  cysts 292 

109.  Impaction  of  teeth  ^vith  abscesses  and  cysts 293 

110.  Impaction  of  teeth  -\\ith  abscesses  and  cysts 293 

111.  Impaction  of  teeth  with  abscesses  and  cysts 293 

112.  Impacted  bicuspid  found  in  a  skull 294 

113.  Impacted  lower  molar 295 

114.  Four  impacted  teeth  in  one  case 296 

115.  Impacted  upper  molar 297 

116.  Impacted   central 298 

117.  Cyst  from   erupting   tooth 298 

118.  Root   cyst 299 

119.  Teeth   from    same    cvst .299 


\ 


XX  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

120.  Cyst  from  developed  tooth 299 

121.  Embryonic  development  of  face 301 

122.  Premaxillary  bone 301 

123.  Cross  section  of  face 303 

124.  Muscles  of  the  soft  palate 304 

125.  Cleft   palate 306 

126.  Large   hypertrophied   tonsils   and   adenoid,   the   latter   visible 

below  the  margin  of  the  soft  palate 307 

T27.     Congenital  microstoma 308 

128-130.     Nelaton's  method  of  operation  in  hare  lip 311 

131-133.     Malgaigne's  method  of  operation  in  hare  lip 311 

134-136.     Mirault-Langenbeck's  method  of  operation  in  hare  lip     .  312 

137-139.     Operation   for   bilateral   hai'e   lijD 312 

140.  Bilateral  incomplete  hare  lip 313 

141.  Result  of  operation 313 

142.  Unilateral  complete  hare  lip 313 

143.  Bilateral   complete    hare   lip,    with   projecting   intermaxillary 

process 314 

144.  Result  after  hare  lip  operation 314 

145.  Result  after  hare  lip  operation 314 

146.  Brown's  model  showing  his  method  of  approximating  maxil- 

laiy  bones 320 

147.  Rose  position 320 

148-149.     Brophy's  periosteal  elevators 321 

150.  Fillebrown's  hoe 321 

151.  Cleft  alveolar  process 322 

152.  Result  of  operation 323 

153.  Operation  for  cleft  alveolar  process 324 

154.  Cleft   palate 325 

155.  Union  of  entire  cleft  after  operation  .........  326 

156.  Cosmetic  result  of  operation 327 

157.  Method    of    forming    and    adjusting    flaps    in    cleft    psrlate 

operations 328 

158.  Method    of    forming    and    adjusting    flaps    in    cleft    palate 

operations 328 

159.  Method    of    forming    and    adjusting    flaps    in    cleft    palate 

operations 329 

160.  The  three  stejis  of  closing  the  soft  palate,  and  practically  the 

same  method  of  closing  the  hard  palate 330 

161.  Left  superior  maxillary  bone  with  associated  parts  ....  331 

162.  Ferguson's  operation  for  unilateral  cleft  palate 331 

163.  Ferguson's  operation  for  unilateral  cleft  palate 331 


LIST    OF    ILLUSTRATIONS  xxi 

FIG.  PAGE 

164.  Author's  method  of  introducing  sutures 332 

165.  Original  curved  needle 333 

166.  Hook  and  eye 333 

167.  A  section  cut  vertically  in  the  region  of  the  second  molar  tooth  335 

168.  A  transverse  vertical   section 335 

169.  A  section  cut  anteriorly  to  the  second  molar  teeth  ....  335 

170.  Anterior-posterior  section  through  the  antrum  near  the  naso- 

antral   septum 

171.  Transverse  section  just  anterior  to  the  ostium  maxillare  .     .  337 

172.  Lateral  wall  of  antrum 338 

173.  X-ray  showing  disease  of  antrum  on  right  side  with  pus  .     .  345 

174.  X-ray  showing  disease  of  the  antral  and  frontal  sinuses  on  the 

left  side,  with  pus 346 

175.  Mouth  after  antral  operation 347 

176.  Deep  injections  for  neuralgia 358 

177.  Method  of  exposing  the  supraorbital  branch  of  the  fifth  nerve  361 

178.  Exposed   infraorbital  branch   of   the   fifth   nerve 361 

179.  Mental  branch  at  foramen  as  exposed  through  the  mouth  .     .  362 

180.  Operation  for  salivary  fistula 367 

181.  Operation  for  salivai-y  fistula 367 

182.  Model  of  ranula  before   operation 372 

183.  Ranula  showing  incision 373 

184.  Sarcoma  of  the  parotid  gland 374 

185.  Impacted  third  upper  molar  causing  spasmodic  ankylosis  .     .  377 

186.  Impacted  third  molar  causing  spasmodic  ankylosis   ....  378 

187.  Resection   of  the  mandibular  condyle 381 

188.  Resection  of  mandible  showing  Gigli  saw  in  position  ....  382 

189.  Result    of    operation 383 

190-192.     Incision   through  skin  and  needle  passing  under  maxilla 

into   mouth 384 

193.  Case  of  ankylosis  before  operation.     Front  view 385 

194.  Case  of  ankylosis  before  operation.     Side  view 386 

195.  Case  of  ankylosis  after  operation.     Side  view 387 

196.  Case  of  ankylosis  after  operation.    Front  view 387 

197.  Dental    splint    swaged    to    fit    the    teeth    and    cemented    into 

position       396 

198.  Angle's  bands 396 

199.  Holding  fractured  mandible  to  maxilla  with  wire  around  pins 

on   the  band 397 

200.  Holding  fragments  in  position  with  a  screw  rod  from  bands  .  398 

201.  Drilling  the  bone  in  a  fractured  mandible 399 

202.  Notched   drill   and  wire 399 


xxii  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

203.  Threading   drill   hole   with   ^^dre 400 

204.  Chisel  used  to  freshen  ends  of  bones  in  old  fractures  ....  400 

205.  Fracture  through  molars,  showing  method  of  making  traction 

to  overcome  a  muscular  spasm  and  approximate  the  bones  401 

206.  Double  fracture,  showing  wires  in  position 402 

207.  Fracture  of  ramus,  with  wires  in  position 403 

208.  Fracture  of  symphysis,  with  wires  in  position 404 

209-210.     Longitudinal  fracture   of  the   alveolar  process,   including 

four  teeth 405 

211.  Obstetric   fracture   of   mandible .  406 

212.  Fracture  of  maxilla,  showing  apparatus 409 

213.  Fracture    of    maxilla,    showing   skull    aj^paratus,    method    of 

api3lying  bandage,  and  result 410 

214.  Fracture  of  maxilla  and  mandible 411 

215-218.     Four  cases  in  which  portions  of  the  maxillae  were  broken 

away  in  an   effort  to  extract  a  tooth 412 

219.  Depressed  fracture  of  the  malar  bone,  before  operation  .     .     .  414 

220.  Depressed  fracture  of  the  malar  bone,  after  operation  .     .     .  415 

221.  Coat  hook  for  elevating  depressed  fractures  of  the  malar  and 

other  bones 416 

222.  Reducing  dislocated  mandible 424 

223.  Epithelioma  about  the  molar  tooth 427 

224.  X-ray    technique 428 

225.  Proper  method  of  taking  X-ray  of  jaw 428 

226.  Impaction  of  lower  left  first  molar 429 

227.  Salivary  calculus  in  the  duet  of  the  submaxillary  gland  .     .     .  430 

228.  Cyst  of  mandible  and  impacted  third  molar  .......  431 


PART    I 
GENERAL    SURGERY 


CHAPTER  I 

BACTEEIA   AND    INFLAMMATION    AND    THEIR   IMMEDIATE    RESULTS 

BACTERIA 

With  the  introduction  of  the  microscope,  some  order  was 
brought  into  understanding  that  group  of  organisms  which 
Linnaeus  had  termed  "chaos."  That  disease  and  decay 
were  due  to  minute  organisms  had  been  the  theory  for  cen- 
turies. Leeuenhoeck  was  able,  by  the  improved  microscope, 
to  demonstrate  microorganisms  in  water,  intestinal  con- 
tents, etc.  He  made  out  short,  straight  and  curved  rods, 
and  described  their  mobility.  Muler  attempted  a  systematic 
classification.  Eayer  and  Davaine,  in  1815,  found  rod- 
shaped  organisms  in  the  blood  of  animals  sick  with  splenic 
fever.  Pasteur  established  the  cause  of  fermentation  and 
the  part  played  by  bacteria  in  the  economy.  Davaine  then 
established  the  nature  of  splenic  fever,  or  anthrax,  which 
has  been  the  foundation  for  our  knowledge  of  the  relation 
of  bacteria  to  disease. 

Morphology  of  Bacteria.— Bacteria  are  made  up  of  a  cell 
membrane,  cell  wall  and  cell  contents.  The  cell  membrane, 
or  capsule,  surrounds  the  organism.  The  cell  wall  lies  be- 
tween the  capsule  and  the  cell  protoplasm,  from  which  it  is 
modified.  It  is  composed  of  cellulose  or  an  albumin  and 
can  easily  be  demonstrated.  The  cell  content  is  mainly  pro- 
toplasm, composed  of  mycoprotein.  As  a  rule,  it  is  homo- 
geneous, but  may  contain  granules,  fluid  spaces,  fat  droplets, 
pigment,  sulphur  and  chlorophyll, 

3 


4  BACTERIA    AND    INFLAMMATION 

Reproduction  of  Bacteria.— Reproduction  takes  place  by 
fission  and  sporulation.  Fission  or  simple  cell  division 
takes  place  when  favorable  conditions,  such  as  heat,  mois- 
ture and  nutrition  exist,  together  with  the  absence  of  the 
deleterious  effects  of  other  bacteria  or  their  products.  The 
cell  elongates,  and  the  cell  wall  constricts,  usually  at  the 
cell  center,  gradually  forming  a  septum  that  divides  the  cell 
into  equal  parts.  This  division  may  take  place  in  one,  two, 
or  three  planes,  depending  upon  the  nature  of  the  bac- 
terium.   Division  may  be  comi^leted  within  fifteen  minutes. 

Biology  of  Bacteria.— Bacteria  cannot  arise  de  novo. 
They  must  develop  from  preexisting  bacteria  or  their 
spores — one  kind  of  bacterium  will  not  produce  another 
kind.  They  are  classified  into  saprophytes,  or  those  that 
live  only  on  dead  organic  matter;  and  parasites,  or  those 
which  live  at  the  exxjense  of  living  bodies.  They  cause 
pathological  conditions  in  the  host;  therefore,  they  are 
called  pathogenic.  Obligate  parasites  or  saprophytes  exist 
^only  under  one  of  the  above  conditions,  while  facultative 
parasites  or  saprophytes  can  develop  under  both  conditions. 

Bacteria  and  Products  of  Bacteria.— The  functions  and 
products  of  bacteria  (vital  actions)  are  destructive  ones, 
splitting  up  higher  nitrogenous  and  non-nitrogenous  com- 
pounds into  simpler  substances.  Sometimes  such  changes 
are  destructive  to  the  bacteria  themselves,  as  when  lactic 
and  butyric  acids  are  formed  in  the  media. 

Substances  found  in  media  of  bacterial  growth  are  as 
follows:  1.  Proteins.  These  are  components  of  the  bac- 
terial cell  proper,  and  may  cause  suppuration  (pyogenic), 
fever  (pyrogenic),  and  inflammatory  processes  (phlogenic). 
2.  Ferments,  secretions  of  the  cell,  which  possess  the  power 
of  breaking  up  the  more  highly  organized  nitrogenous  and 
non-nitrogenous  compounds  into  simple  and  more  diffusi- 
ble substances.  The  action  of  ferments  upon  nitrogenous 
compounds  is  called  fermentation ;  upon  non-nitrogenous 
compounds  it  is  known  as  putrefaction,  which  often  pro- 


BACTERIA  5 

duces  odorous  gases  and  ptomaines  (complex  alkaloids 
resembling  those  found  in  plants).  The  principal  bacterial 
ferments  are:  Proteolytic,  diastatic,  inverting,  emulsify- 
ing, coagulating,  hydrolytic,  fat-splitting,  oxidizing,  and 
nitrifying.  3.  Substances  that  are  the  result  of  the  action 
of  bacteria  upon  the  medium  of  growth,  (a)  Toxins,  poi- 
sonous substances  akin  to  the  venom  of  serpents  and  other 
animals,  and  to  certain  poisonous  principals  of  plants. 
They  may  be  divided  into  (1)  those  which  are  within  the 
body  of  the  bacteria  and  are  set  free  by  the  disintegration 
of  the  organism;  and  (2)  those  which  are  excreted  by  the 
bacteria  and  are  found  in  the  surrounding  media,  (b)  Pig- 
ments, (c)  Photogenesis.  (d)  Fluorescence,  (e)  Odors. 
(f)  Gas. 

Effects  of  Bacteria  (Generally  Known  as  Infections) . — 
When  bacteria  have  gained  an  entrance  into  the  animal 
body,  the  effects  may  be  either  local  or  general.  Local 
effects  are  of  two  kinds:  (a)  Mechanical,  which  by  their 
mere  presence  in  the  tissues  may  cause  tissue  changes  of 
two  kinds — proliferation,  due  to  irritation,  and  thrombosis 
(by  rapid  multiplication)  and  its  consequent  conditions; 
(b)  toxic,  which  are  due  to  the  action  of  their  toxins  upon 
the  cells  with  which  they  are  in  direct  contact,  and  which 
may  result  in  proliferation,  cell  degeneration  and  necro- 
biosis. 

General  effects  (intoxications)  are  due  entirely  to  the 
circulation  of  the  toxins  of  the  bacteria  in  the  blood.  This 
may  occur  in  two  ways :  (a)  From  a  primary  focus  (point 
of  entrance) — bacteria  may  remain  at  the  point  of  entrance 
and  liberate  toxins  which  are  absorbed  and  circulated  by 
the  blood,  causing  disease,  e.  g.,  tetanus,  diphtheria  or  the 
sapremia  due  to  pyogenic  organisms;  (b)  from  a  secondary 
focus — bacteria  may  also  circulate  in  the  body  fluids  and 
find  lodgment  in  any  of  the  organs,  causing  both  local 
changes  in  the  tissue  and  general  intoxication,  such  as  the 
bacillus    of    Eberth     (typhoid    fever),    pneumococcus    of 


6  BACTERIA    AND    INFLAMMATION 

Frankel  (pneumonia),  diplococcus  intracellularis  of  Weich- 
selbaum  (cerebro-spinal  fever),  streptococcus  (septicemia 
and  pyemia). 

Immunity  denotes  that  condition  of  an  organism  wliich 
enables  it  to  resist  an  attack  of  the  particular  bacteria  and 
their  toxic  secretions  against  which  it  is  said  to  be  immune. 

Infectious  Diseases  Due  to  Bacteria. — An  infection  is 
the  invasion  of  the  body  by  a  disease-producing  microor- 
ganism. The  time  when  the  germ  enters  the  body  is  not 
always  known  to  the  patient,  and  some  time  usually  elapses 
between  the  time  of  actual  entrance  and  the  appearance  of 
the  resulting  symptoms.  This  time  is  called  the  period  of 
incubation.  There  is,  at  this  time,  no  great  distinction 
between  the  terms  infection  and  contagion,  unless  it  is  that 
contagion  is  used  to  denote  infection  by  personal  contact. 

Of  the  suppurative  diseases,  the  staphylococcus  group 
may  be  divided  as  follows:  (a)  Staphylococcus  pyogenes 
aureus  is  found  in  lesions  such  as  furuncles,  abscesses,  car- 
buncles and  ulcerations  of  the  skin  or  mucous  membranes. 
It  is  frequently  seen  in  suppurative  inflammations,  such 
as  malignant  endocarditis,  osteomyelitis,  appendiceal  ab- 
scesses, etc.  It  is  generally  found  in  focal  lesions.  Other 
organisms  may  also  be  associated  in  these  lesions,  (b) 
Staphylococcus  pyogenes  albus  is  far  less  virulent  than  the 
aureus  and  is  frequently  found  as  a  harmless  parasite  of 
the  skin.  Associated  with  other  microorganisms,  it  occurs 
generally  in  abscesses  and  suppurative  diseases,  (c)  Staphy- 
lococcus pyogenes  citreus  is  not  very  common  nor  viru- 
lent. 

In  the  streptococcus  group  are  included  various  bacteria 
that  resemble  each  other  very  closely,  (a)  Streptococcus 
pyogenes  is  found  distributed  much  the  same  as  the  staphy- 
lococci, but  not  generally  in  the  healthy  body.  It  is  found 
upon  the  mucous  membranes  or  in  the  various  secretions 
or  excretions  of  the  body  and  occasionally  occurs  in  focal 
lesions.    It  may  occur  in  generalized  septicopyemia,  infec- 


INFLAMMATION  7 

tious  endometritis  and  sometimes  in  ulcerative  endocardi- 
tis. It  may  occur  in  persons  with  previous  good  health  or 
in  the  course  of  infectious  diseases,  such  as  scarlatina, 
measles  and  la  grippe ;  also  in  sore  throats  resembling  diph- 
theria (pseudodiphtheria).  It  is  always  found  in  cases  of 
erysipelas,  (b)  Streptococcus  intracellularis  meningitidis, 
also  called  meningococcus  or  diplococcus  meningitidis,  is 
found  in  meningeal  pus,  nasal  mucus,  sputum  and  urine  of 
those  sick  with  epidemic  cerebro-spinal  meningitis.  Other 
microorganisms  associated  in  meningitis  are  the  pneumo- 
coccus,  streptococcus  and  staphylococcus  pyogenes,  typhoid 
and  colon  bacilli,  influenza  bacillus,  etc. 

INFLAMMATION 

Inflammation  is  the  reaction  to  various  forms  of  irrita- 
tion which  occurs  in  tissues  and  is  characterized  by  the 
cardinal  symptoms  of  heat  (calor),  redness  (rubor),  pain 
(dolor),  swelling  (tumor)  and,  later,  altered  function  (func- 
tio  laesae).  Its  etiology  includes  irritation  by  mechanical 
means,  as  in  fractures  and  wounds ;  chemical  means,  as  by 
strong  acids ;  electrical  means ;  thermal  means,  or  opposite, 
burns  and  frost  bites;  microorganisms;  metabolic  influ- 
ences, as  in  gout,  etc. ;  mental  influence,  as  in  hypnosis,  etc. 

The  phenomena  of  inflammation  include  vascular,  exuda- 
tive, proliferative  and  degenerative  changes. 

Vascular  Changes.— The  vascular  changes  are,  first,  a 
probable  momentary  reflex  contraction  of  the  arteries 
(rarely  observed),  then  a  dilatation  of  the  arteries,  due  to 
some  degeneration  of  the  vessel  walls  mostly,  but  in  part 
to  nervous  reflex.  The  blood  courses  quickly  at  first,  fol- 
lowed by  a  slowing  of  the  current,  with  sometimes  complete 
stoppage  (stasis),  brought  about  by  the  damaged  endothe- 
lial cells,  which  swell  and  increase  in  adhesiveness,  thus 
encroaching  upon  the  lumen  of  the  vessel.  This  condition 
is  followed  by  exudative  changes. 


8  BACTERIA    AND    INFLAMMATION 

Exudative  Changes.— The  leucocytes  in  the  plasmatic 
zone  of  the  blood  stream  increase  in  number  and  cling  to 
the  vessel  wall.  The  leucocytes  then  migrate  through  the 
vessel  wall  into  the  tissues.  This  is  brought  about  by  the 
leucocytes'  own  ameboid  movement  and  chemotaxis  (posi- 
tive) and  the  attractive  chemical  influence  at  the  site  of 
irritation ;  and  increased  permeability  of  the  vessel  wall  and 
blood  pressure  aid  to  a  minor  extent.  Coincidentally  with 
migration  there  is  exudation  of  altered  blood  plasma,  the 
amount  and  character  of  which  vary  with  the  nature  and 
condition  of  the  tissues  affected  and  the  character  of  the 
irritant.  The  exudate  is  relatively  rich  in  albumen  and 
more  coagulable  than  dropsical  fluid.  There  is  also  an 
escape  of  the  red  corpuscles  (diapedesis  of  red  corpuscle) 
from  the  capillaries.  It  is  a  passive  process  due  to  blood 
pressure  and  is  most  marked  when  stasis  has  occurred. 

Proliferative  Changes.— Some  authorities  hold  that  pro- 
liferative changes  are  not  in  reality  a  part  of  inflammation, 
but  are  for  the  purpose  of  tissue  repair  after  inflammation. 
They  will,  however,  be  regarded  here  as  a  part  of  inflam- 
mation. In  the  inflamed  area,  especially  at  the  periphery, 
the  tissue  is  infiltrated  with  round  cells  resembling  lympho- 
cytes or  mononuclear  leucocytes  frequently  showing  evi- 
dences of  karyokinesis.  They  are  derived  from  fixed  con- 
nective tissue  cells  and  the  endothelia  of  lymph  spaces.  The 
newly-formed  connective  tissue  cells  become  in  part  wander- 
ing and  more  or  less  phagocytic  in  nature ;  and  in  part  fixed, 
assuming  a  regenerative  role.  They  are  frequently  called 
fibroblastic  cells.  The  appearance  of  the  tissue  at  this 
stage  is  characteristic  and  is  termed  round-cell  infiltration. 
Granulation  tissue  is  formed  by  active  proliferative 
changes,  multiplication  of  new  blood  vessels  and  preexist- 
ing vessels'  endothelial  outgrowth,  all  surrounded  by  vari- 
ous forms  of  round  cells.  It  is  frequently  seen  in  the  floor 
of  ulcers.    It  is  more  properly  a  regeneration. 

Degenerative  Changes.— The  nature  of  the  degeneration 


INFLAMMATION  9 

depends  upon  the  severity  of  the  irritation,  very  powerful 
irritants  causing  necrosis  at  once.  Irritants  which  merely 
disorder  but  do  not  entirely  destroy  the  cells  are  apt  to 
cause  inflammation.  The  degenerative  changes  may  be 
physiologic  or  there  may  be  structural  changes,  such  as 
cloudy  swelling,  mucoid  degeneration,  liquefaction  and  fatty 
or  coagulation  necrosis.  These  degenerations,  though  pri- 
mary, are  often  followed  by  a  secondary  degeneration  which 
may  serve  to  spread  and  intensify  the  original  inflamma- 
tion. 

Varieties  of  Inflammation.— Ca fa rr/^rtZ  inflammation, 
mucous  inflammation  or  catarrh,  occurs  on  the  mucous 
membranes  in  the  nose,  throat,  bronchi,  stomach,  bowels, 
etc.  The  mucosa  is  congested,  a  serous  exudation  is  dis- 
charged from  the  surface,  and  to  some  extent  it  is  retained 
in  the  tissue,  causing  edematous  swellings.  The  mucous 
glands  increase  their  secretion  and  leucocytes  escape. 

Serous  mflammation  is  characterized  by  an  abundant 
exudate  of  serum  with  little  cellular  matter.  It  is  seen  in 
pleural  or  i3eritonitic  effusions  and  as  edema  of  the  larynx, 
etc. 

Fibrinous  (croupous)  inflammation  is  characterized  by 
a  thick  deposit  of  fibrin  and  occurs  on  the  serous  surfaces, 
as  in  peritonitis;  in  the  larynx  and  the  bronchi  in  acute 
infections,  as  typhoid  fever,  smallpox  and  pyemia;  and  in 
the  lungs  in  pneumonia.  The  term  "sero-fibrinous"  is 
applied  when  the  inflammation  is  associated  with  serous 
exudation  and  "fibrino-purulent"  when  the  exudate  is  puru- 
lent. 

Diphtheritic  inflammation  is  of  the  same  nature  as  the 
fibrinous,  but  differs  in  that  it  is  much  more  severe  and 
there  is  associated  with  the  coagulated  exudate  a  necrosis 
of  the  cells  of  the  part  involved. 

Parenchymatous  inflammation  is  a  term  applied  to  an 
inflammation  when  it  attacks  the  proper  tissues  of  an  organ, 
as  in  nephritis,  and  leads  to  degeneration  of  its  active  cells. 


10  BACTERIA    AND    INFLAMMATION 

Productive  inflammation  is  referred  to  as  interstitial  in- 
flammation in  contradistinction  to  the  parenchymatous 
form.  The  proliferative  changes  predominate  over  exuda- 
tion and  degeneration. 

Hyperemia — Congestion. — Hyperemia,  or  congestion,  is 
an  increase  in  the  quantity  of  blood  in  a  tissue  or  an  organ 
of  the  body,  and  is  divided  into  active  and  passive  forms. 
Active,  acute,  or  arterial  hyperemia  or  congestion  is  due  to 
an  increase  of  the  blood  flow  to  a  part.  It  occurs  physio- 
logically during  the  functional  activity  of  the  organs  and 
pathologically  from  any  condition  which  interferes  with  the 
nervous  control  of  the  caliber  of  the  arteries,  when  it  may 
act  (1)  through  their  local  nerve  plexuses  or  the  vasomotor 
center  in  the  medulla.  Under  these  conditions  it  is  known 
as  (a)  neuroparalytic  hyperemia,  in  which  the  vaso-con- 
strictor  fibers  of  the  sympathetic  nerves  are  cut  off  or  com- 
pressed by  tumors  or  (b)  neurotoxic  hyperemia,  in  which 
the  vaso-dilators  in  the  spinal  nerves  are  stimulated  as  in 
neuritis.  Toxic  causes  or  fevers  may  act  similarly  through 
the  vasomotor  centers,  causing  superficial  hyperemia.  It 
may  act  (2)  by  local  affections  of  the  vessel  walls,  due  to 
injury  by  heat,  traumatism,  inflammation,  drugs  or  vascular 
fatigue,  or  following  temporary  stoppage  of  the  circulation, 
as  frequently  seen  on  the  removal  of  the  rubber  bandage 
after  a  bloodless  amputation  or  in  the  abdominal  vessels 
when  the  pressure  of  an  ascites  or  large  tumor  is  suddenly 
relieved.  Arterial  hyperemia  is  the  initial  phenomenon 
of  inflammation,  but  transudation  takes  place  only  when 
the  capillary  endothelium  is  damaged. 

Passive  or  venous  hyperemia  is  due  to  an  obstruction  of 
the  outflow  of  blood  through  the  veins  by :  failure  of  the  left 
heart  to  provide  arterial  pressure ;  failure  of  the  right  heart 
to  empty  the  veins;  weak  heart  power  following  attempts 
to  overcome  the  obstruction  in  veins  by  thrombi;  pressure 
by  tumor,  etc.;  or  the  resistance  of  narrowed  arteries 
(atheroma). 


NECROSIS  11 

Results  of  Inflammation.— An  early  consequence  of  in- 
flammation is  infiltration,  which  terminates  in  either  hyper- 
trophy, hyperplasia,  atrophy,  degeneration,  or  resolution, 
in  all  of  which  conditions  the  normal  histological  structures 
have  been  changed. 

Infiltration  is  the  deposit  or  accumulation  of  any  solid 
or  fluid  morbid  product  in  the  midst  of  tissue  elements. 

Hypertrophy  is  an  increase  in  the  size  of  the  tissue  ele- 
ments without  marked  alterations  from  the  normal  struc- 
ture, and  it  is  caused  by  (a)  an  increase  in  functional 
demand,  (b)  disturbances  of  the  nervous  system,  and  (c) 
continued  congestion. 

Hyperplasia  is  an  increase  in  the  number  of  cells  while 
they  remain  normal  in  size. 

Atrophy  is  a  decrease  in  the  size  of  a  tissue  or  an  organ. 
The  cause  may  be  defective  development,  nerve  injury,  non- 
use,  occlusion  of  the  blood  vessels,  or  pressure. 

Degeneration  is  the  retrograde  change  which  takes  place 
in  a  cell  or  tissue  by  which  its  integrity  is  altered  in  the 
direction  of  lowered  vitality.  The  protoplasm  of  the  cell 
may  be  converted  into  substances  normal  to  it  in  kind  and 
quantity.  The  cell  may  break  down  and  be  absorbed  or  its 
altered  debris  may  well  remain  in  one  form  or  another. 

Resolution  is  a  restoration  or  a  repair  after  a  patho- 
logical change  from  any  cause.  When  resolution  occurs, 
the  normal  histological  structure  of  the  tissues  may  have 
been  destroyed  to  some  extent,  yet  the  functional  usefulness 
of  the  parts  which  have  been  inflamed  may  remain  normal. 

NECROSIS 

Necrosis  is  the  local  death  of  tissue.  Necrobiosis  is  the 
death  of  individual  cells.  The  causes  are:  (1)  Circulatory 
derangements:  (a)  Acute  and  chronic  ischemia,  produced 
by  embolism,  thrombosis,  arteriosclerosis,  atheroma,  extra- 
arterial  blood  pressure,  cardiac  spasms,  ergotism  and  Ray- 


12  BACTERIA    AND    INFLAMMATION 

naud's  disease;  (b)  venous  stagnation;  (c)  anemia;  (d) 
cachexia;  (e)  senility;  (f)  diabetes — (2)  Trophic  derange- 
ments, due  to  trophic  disturbances,  as  bed  sores  and  mye- 
letic  cystitis — (3)  Intoxications,  due  to  animal,  vegetable, 
bacterial  and  inorganic  poisons — (4)  Traumatism,  due  to 
pressure  per  se  or  the  pressure  of  calculi,  concretions,  en- 
teroliths or  exostoses — (5)  Inflammations. 

Varieties  of  lUecrosis.— Coagulation  Necrosis. — In  this 
necrosis  the  proteid  of  the  tissue  suffers  death  from 
changes  similar  to  coagulation.  Macroscopically  the  tissue 
is  of  a  glazed,  opaque,  waxy  appearance,  pale  and  firm. 
Later  the  tissue  becomes  grayish  and  is  inclined  to  soften. 
Microscopically  there  is  a  fixed  exudate  in  the  tissues. 
Fibrin  granules  or  fibrils  are  present.  Fibrinoids,  which  do 
not  react  to  stains  like  the  fibrin,  are  also  seen.  During 
the  early  stage  the  nuclei  stain  faintly  and  are  of  homo- 
geneous appearance.  The  cell  disintegrates  and  the  stria- 
tions  disappear  in  the  muscles.  All  other  cells  in  the  area 
suffer  the  fate  of  the  fixed  tissues. 

Liquefaction  necrosis  or  coUiquation  is  the  death  of  tis- 
sue with  liquefaction.  It  is  divided  into  primary  liquefac- 
tion necrosis,  as  seen  frequently  in  the  central  nervous  sys- 
tem, where  it  follows  pathologic  conditions  which  elsewhere 
would  produce  coagulation ;  and  secondary  liquefaction  ne- 
crosis, a  form  in  which  the  areas  of  coagulation  necrosis, 
cheesy  necrosis,  inflammation,  gangrenous  tissue  and  tu- 
mors may  become  liquefied. 

Caseation  is  spoken  of  where  coagulation  necrosis  takes 
on  a  cheese-like  appearance.  It  is  secondary  to  coagulation 
necrosis  and  is  typical  of  tuberculosis  and  syphilis. 

Fat  necrosis  occurs  in  very  stout  people  and  is  confined 
to  small  areas  in  the  normal  fat. 

GANGRENE 

Gangrene  is  the  putrefaction  of  areas  of  necrosis.  It 
may  be  classed  as:    (1)  Primary,  when  a  particular  bac- 


SUPPURATIVE    INFLAMMATION  13 

terium  produces  a  direct  gangrenous  result,  as  in  malignant 
edema,  anthrax,  etc.;  (2)  secondary,  when  saprophytic  bac- 
teria decompose  an  area  already  dead. 

The  varieties  are :  Dry  gangrene,  due  to  arterial  dis- 
turbance or  occlusion,  senility,  arterial  embolism,  throm- 
bosis, freezing,  ergotism  or  Raynaud's  disease;  moist  gan- 
grene, which  generally  results  from  extensive  venous  occlu- 
sion, but  in  some  cases  may  be  due  to  arterial  occlusion; 
embolic,  diabetic,  senile,  diphtheritic,  hospital  and  malig- 
nant edema. 

SUPPURATIVE  INFLAMMATION 

Suppurative  inflammation  is  caused  by  infection  with 
pyogenic  microorganisms.  It  is  characterized  by  an  abun- 
dance of  emigrated  leucocytes  and  the  tendency  to  liquefac- 
tion. The  most  common  bacteria  producing  it  are  the  pyo- 
genic staphylococci  and  streptococci,  but  other  forms  not 
generally  considered  pathogenic  may  also  cause  it,  such  as 
the  typhoid  and  colon  bacilli,  gonococcus  and  others.  Bac- 
teria, entering  the  tissue  by  means  of  the  blood  or  other- 
wise, first  cause  degeneration  or  necrosis;  congestion  fol- 
lows with  exudation  of  leucocytes  and  plasma  and  more  or 
less  fibrin  formation ;  and  finally  there  is  a  softening  of  the 
whole  area  involved  from  the  action  of  the  bacteria  on  the 
cells,  creating  a  ferment. 

Pus  is  a  fluid  resulting  from  the  process  of  suppuration 
and  consists  of  a  liquid  part  (liquor  puris)  and  a  corpuscu- 
lar part.  The  liquid  part  is  made  up  of  a  less  coagulable 
blood  plasma  containing  quantities  of  albumose.  The  cor- 
jDuscles  are  chiefly  more  or  less  degenerated  polymorpho- 
nuclear leucocytes.  Pus,  in  the  modern  views  of  pathology, 
signifies  the  preexistence  of  phagocytes,  i.  e.,  the  presence 
of  pathogenic  bacteria,  which  must  have  destroyed  the  leu- 
cocytes after  their  escape  from  the  blood  vessel.  The  dis- 
charge found  around  the  drainage  tube  from  an  aseptic 


n  BACTERIA    AND    INFLAMMATION 

cavity  must  not  be  confounded  with  pus,  or  considered  pus, 
since  it  contains  no  phagocytes,  but  reparative  serum  and 
some  leucocytes. 

An  abscess  is  a  circumscribed  cavity  containing  pus. 
Previous  to  abscess  formation,  infection  may  take  the  form 
of  cellulitis  or  an  inflammation  of  the  ceUular  structures 
under  the  skin,  or  lymphangitis;  or  the  passage  of  the  bac- 
teria of  infection  along  the  hmiphatic  vessels  may  result 
in  infiltration  and  suppuration  of  neighboring  IjTuphatic 
glands.  The  course  of  the  abscess  depends  entirely  upon 
the  variety  of  bacterium  producing  the  suppuration.  Acute 
abscess  is  usually  caused  by  a  streptococcic  germ,  while 
suppurative  changes  run  a  subacute  course  and  are  usually 
dependent  upon  the  staphylococcus,  pneumococcus,  or  the 
bacillus  of  typhoid.  Other  chronic  suppurative  changes  are 
usually  those  dependent  upon  tuberculosis  or  syphilis. 

An  ulcer  is  of  the  same  construction  as  an  abscess  except 
that  it  appears  with  erosion  upon  the  skin  or  mucous  sur- 
faces. It  is  pathologically  the  same  as  suppuration  except 
that  the  discharge,  instead  of  collecting  in  a  closed  cavity 
and  forming  an  abscess,  escapes  immediately  upon  the  sur- 
face. The  classification  of  ulcers  is  based  upon  their  loca- 
tion, as  tonsilar,  or  upon  their  cause,  as  tuberculous,  syphi- 
litic, gouty  or  traumatic.  Pressure  from  an  artificial 
denture  frequently  results  in  ulceration  of  the  mucous 
membrane  of  the  mouth, 

A  sinus  is  an  opening  from  the  skin  or  mucous  surface 
leading  into  a  focus  of  suppuration  or  into  an  abnormal 
cavity.  Characteristic  illustrations  of  sinus  are  those  open- 
ings leading  into  an  alveolar  abscess  which  has  resulted 
from  a  carious  tooth  or  bone  disease.  Tuberculous  sinuses 
are  frequently  seen  in  diseases  of  the  hip,  spine  and  other 
joints. 

A  fistula  is  an  abnormal  canal  connecting  a  normal  cav- 
ity with  the  skin  or  mucous  membrane.  A  fistula  results 
from  suppuration  or  injury.     Illustrations  of  the  former 


SUPPURATIVE    INFLAMMATION  15 

may  be  found  when  the  antrum  communicates  with  the 
mouth,  the  bladder  with  the  vagina,  or  the  stomach  with 
the  external  abdominal  surface.  An  illustration  of  fistula 
from  injury  may  be  found  when  Stenson's  duct  has  been 
severed  in  its  course  by  saber  wounds  or  other  varieties 
of  injury  and  the  salivary  fluid  discharges  upon  the  external 
surface  of  the  face  instead  of  within  the  oral  cavity.  Ex- 
amples of  fistula  from  other  causes  are  vesico-vaginal  and 
recto-vesical.  Congenital  fistulas  are  frequently  found  in 
the  neck  and  in  branchial  or  unobliterated  fetal  ducts,  as 
the  urachus. 


CHAPTEE  II 


NON-SPECIPIC    INEECTIONS 


In  addition  to  the  immediate  symptoms  and  conditions 
following  infections,  there  are  occasionally  developed  rare 
or  remote  sequelaB  wliicli  have  typical  symptoms  and  will 
be  given  special  consideration.  These  conditions  include 
cellulitis,  sapremia,  septicemia  and  pyemia. 

CELLULITIS 

Cellulitis  is  an  acute  inflammatory  infection  resulting 
from  the  introduction  of  some  organism,  commonly  the 
streptococcus  pyogenes,  into  the  cellular  connective  tissue  of 
the  tegument,  intermuscular  septa,  tendon  sheaths,  or  other 
structures.  It  always  arises  from  inoculation  either  from 
a  small  and  superficial  injury,  such  as  a  pin-prick,  or  from 
more  extensive  lacerations  of  the  skin.  Pus  formation  gen- 
erally follows,  but  not  always.  The  extension  is  usually 
confined  to  the  areolar  tissues  and  is  generally  by  route 
of  the  lymphatics.  Sloughing  of  the  tissues  of  low  vitality, 
such  as  fat,  fascia  or  tendon,  is  Cjuite  common. 

Clinical  Features.— The  first  symptom  is  a  distinct  chill, 
followed  by  a  temperature  of  103°  to  105°  F.,  with  a  pulse 
proportionately  increased,  which  is  small,  feeble,  and  often 
irregular.  The  face  is  flushed,  the  tongue  is  dry  and  brown, 
and  there  is  frequently  delirium,  especially  during  the  night. 
Local  sj^mptoms  are  swelling  and  edema  of  the  skin,  which 
assumes  a  dark  red  color.  To  the  touch  it  is  firm,  hot  and 
tender.    There  is  also  local  burning  pain.    Blebs  containing 

16 


SAPREMIA  17 

dark  serous  fluid  are  frequently  found.  The  approximal 
lymphatics  are  usually  enlarged  and  tender.  As  the  pus 
formation  advances,  the  skin  becomes  soft  and  boggy  and 
eventually  breaks,  permitting  the  discharge  of  a  thick  gru- 
mous  liquid.  Occasionally  several  pus  cavities  fuse  into  a 
large,  distinct  fluctuating  abscess.  When  gas  is  accumu- 
lated it  gives  rise  to  emphysema.  Sloughing  of  the  ligaments, 
tendons  and  fascia  is  quite  common.  The  constitutional 
symptoms  are  in  proportion  to  the  size  of  the  area  of  in- 
volvement and  to  the  absorption  of  toxins  of  the  strepto- 
cocci, a  condition  of  septicemia  if  present.  If  secondary 
abscesses  result,  a  pyemic  condition  is  developed. 

A  remote  result  of  cellulitis  is  the  destruction  of  tendons, 
ligaments  and  fascia  which  have  been  involved  in  the  ne- 
crotic area,  causing  the  destruction  of  functional  usefulness 
of  the  part,  on  account  of  the  adhesions  and  sloughing. 

Treatment.— The  treatment  is  early  and  free  incision, 
with  disinfection  of  the  infected  area  with  tincture  of 
iodin,  alcohol,  phenol,  permanganate  of  potash,  etc. 
After  free  incision,  continuous  irrigation  or  continuous  im- 
mersion in  an  antiseptic  water  bath  is  very  proper  treat- 
ment. 

SAPREMIA 

Sapremia  is  an  intoxication  produced  by  the  absorption 
of  the  products  of  putrefaction,  or  decay  of  a  retained  ma- 
terial within  a  more  or  less  closed  cavity.  After  fractures 
and  other  injuries  and  unclean  surgical  operations,  there  is 
thrown  out  reparative  lymph  with  blood-clot  and  other  dis- 
organized materials,  which  become  infected  by  saprophytes 
producing  gas  and  ptomaines.  These  are  absorbed  into  the 
lymphatic  and  general  circulation,  profoundly  impressing 
the  system. 

Symptoms.— The  symptoms  begin  from  twenty-four  to 
thirty-six  hours  after  the  time  of  the  accident  or  operation, 
the  first  one  being  a  slight  chill  or  rigor  followed  by  eleva- 


18  NON-SPECIFIC    INFECTIONS 

tion  of  temperature,  not  usually  very  high.  There  is  dry- 
ness of  the  tongue  with  coating,  flushed  face,  pyrexia,  head- 
ache, malaise  and  mental  disturbances.  There  may  be 
nausea  and  vomiting,  with  diarrhea  or  active  purging,  or 
constipation,  which  is  usually  found  early  and  may  continue 
until  a  purgative  is  administered.  The  urine  contains  an 
excessive  amount  of  solids.  The  same  chain  of  symptoms 
may  follow  the  closure  of  a  sinus  from  an  old  bone  disease, 
but  when  the  sinus  is  incised  or  spontaneously  erupts,  symp- 
toms disappear  in  a  few  hours. 

Treatment.— The  treatment  is  medical  and  operative. 
The  former  consists  in  administering  a  prompt  purgative 
to  be  followed  by  diaphoretics  and  febrifuges.  The  most 
important  step  in  treatment  is  to  remove  the  source  of 
infection.  If  it  is  a  blood-clot  enclosed  after  an  operation, 
the  wound  should  be  opened  and  cleansed.  If  it  is  a  com- 
pound fracture  or  injury,  free  drainage  should  be  secured. 
When  the  source  of  intoxication  is  removed  before  parasitic 
infection  occurs  and  extends  to  living  tissue,  symptoms  dis- 
appear and  the  patient  is  restored  to  a  normal  condition 
except  for  the  exhaustion  following  such  intoxication. 

Symptoms  characteristic  of  sapremia  may  follow  the 
extraction  of  a  tooth,  the  chill  and  fever  being  in  some  in- 
stances quite  severe.  When  an  unhealthy  tooth  is  filled, 
or  when  the  operator  fails  to  remove  all  decay  and  thor- 
oughly prepare  the  cavity  before  filling,  there  is  set  up  an 
infection  of  the  root  canal,  producing  typical  sapremia 
symptoms.  If  drainage  is  established  either  by  the  removal 
of  a  filling,  when  this  is  the  cause,  or  by  making  an  opening 
into  the  center  of  infection  through  a  root  canal  or  through 
the  alveolus,  active  symptoms  usually  subside. 

SEPTICEMIA 

Septicemia  is  an  intoxication  of  the  system  by  bacteria 
of  disease   or  their  products,   resulting  in  constitutional 


SEPTICEMIA  19 

symptoms,  usually  appearing  with  regularity.  Sapremia, 
as  above  described,  disappears  generally,  but  may  continue 
for  some  days,  when  the  slight  intoxication  becomes  vio- 
lent. In  other  cases  there  may  be  no  symptoms  until  septi- 
cemia is  violently  ushered  in.  It  begins  not  earlier  than  the 
second,  and  usually  not  until  the  third  or  fourth  day  or 
later,  after  the  injury  or  operation  furnishing  the  intoxi- 
cant. 

Symptoms.— The  first  symptom  is  a  chill,  which  is  usu- 
ally quite  severe,  lasting  for  from  ten  to  sixty  minutes,  de- 
pending upon  the  amount  of  intoxication.  In  case  a  sa- 
premic  condition  has  preceded,  even  if  of  a  very  mild  type, 
there  will  be  loss  of  appetite,  headache  and  depression.  The 
chill  is  followed  by  high  temperature,  continuous  in  charac- 
ter throughout  the  course  of  infection.  Bigors  or  even  chills 
may  recur  during  the  course,  resembling  malarial  chills. 
As  is  the  case  in  all  continued  febrile  conditions,  the  tem- 
perature is  higher  in  the  afternoon  and  evening.  In  many 
septic  infections  the  entire  lymphatic  system  becomes  in- 
volved, the  glands  are  enlarged  and  tender,  the  vessels 
thick  and  swollen,  the  condition  being  known  as  lymphangi- 
tis. ,  The  lymph  nodes  continue  in  this  condition  until  the 
source  of  the  poison  is  removed.  The  spleen  is  especially 
involved.  The  eyes  become  suffused  and  the  skin  red  and 
mottled.  The  pulse  is  rapid  and  loses  its  usual  force.  The 
tongue  is  coated,  the  alimentary  functions  are  disconcerted 
and  diarrhea  not  infrequently  develops.  The  skin,  which 
is  hot  and  dry  during  the  early  course,  becomes  cold  and 
clammy,  and  the  prostration  is  more  marked.  The  urine 
is  reduced  in  quantity  or  may  be  suppressed  entirely.  Stu- 
por may  pass  over  into  delirium,  followed  by  coma,  collapse 
and  death.  Such  complications  and  sequelae  as  degenerative 
changes  in  the  kidneys,  veins,  endocardium,  meninges, 
pleura  and  the  mucous  surfaces  are  not  infrequent.  The 
post-mortem  changes  in  the  organs  are  not  marked,  except 
the  infective  enlargement  already  mentioned.     The  blood. 


20  NON-SPECIFIC    INFECTIONS 

instead  of  coagulating  and  separating  into  serum  and  clot, 
has  the  consistency  of  pine  tar  and  is  about  the  same  color 
or  slightly  darker. 

Treatment.— The  treatment  of  septicemia  consists  in  re- 
moving the  source  of  the  intoxication.  First,  wounds  should 
be  reopened  and  slough  and  clots  removed,  surfaces  cu- 
retted, irrigated  with  hot  water  and  thoroughly  disinfected 
with  iodin,  mercuric  chlorid,  or  some  other  antiseptic. 
After  the  wound  is  thoroughly  cleansed  it  may  be  partially 
closed,  drainage  being  established  by  the  introduction  of 
iodoform  gauze  or  drainage  tubes  to  permit  daily  irriga- 
tion. When  gauze  is  used  it  should  be  removed  and  the 
cavity  repacked  every  day.  A  ten-per-cent  Lugol's  solu- 
tion of  iodin  is  ideal  for  daily  irrigation. 

The  general  treatment  is  important  and  consists  in  the 
administration  of  stimulants  and  tonics,  as  tincture  of  fer- 
ric chlorid,  or  some  other  form  of  iron,  strychnia,  etc.  All 
excretory  organs  must  be  kept  active  by  the  administration 
of  diuretics,  diaphoretics,  and  cathartics,  not  to  the  extent 
of  reducing  the  vitality,  which  is  already  very  low,  but  suf- 
ficient to  insure  healthy  action. 

PYEMIA 

Pyemia  is  septicemia  to  which  is  added  thrombosis,  em- 
bolism and  suppuration  in  two  or  more  remote  parts  of  the 
body,  developing  simultaneously  or  successively. 

In  some  cases  of  septicemia  there  is  a  tendency  to  the 
formation  of  zooglea  along  blood  channels,  setting  up  a 
mycotic  phlebitis  or  thrombo-phlebitis.  Portions  of  a 
thrombus  thus  formed  are  washed  from  the  wall  of  the 
vessel  and  carried  along  the  blood  current  until  they  are 
stopped  by  the  contraction  of  the  channel,  plugging  the  ves- 
sel and  shutting  off  the  blood  supply  to  the  area  beyond, 
resulting  in  suppuration.  When  a  secondary  abscess 
follows  the  first,  it  is  known  as  a  metastatic  abscess.    Small 


PYEMIA  21 

thrombi  may  be  carried  within  the  heart  and  cling  to  the 
endocardium  over  the  valve  or  at  other  points,  producing 
an  endocarditis.  These  abscesses  develojj  from  two  to  six 
weeks  after  the  onset  of  the  symptoms.  Peridental  ab- 
scesses have  been  the  source  of  pyemic  conditions  in  other 
parts  of  the  body. 

Symptoms.— The  symptoms  of  pyemia  are  those  of  sep- 
ticemia, except  that  they  are  more  marked  and  there  are 
recurring  chills.  The  temperature  is  more  vacillating,  rang- 
ing from  100°  to  105''  F.  The  condition  is  frequently 
treated  as  malarial  fever,  but  in  the  latter  the  chill  returns 
at  the  same  hour  every  two  or  three  days,  while  in  pyemia 
there  is  no  regularity.  No  parts  of  the  body  are  exempt, 
but  the  most  frequent  locations  for  pyemic  suppuration  are 
the  lymphatic  glands,  liver,  spleen,  lungs,  the  epiphyses  of 
the  long  bones,  and  especially  the  joints  and  the  sinuses  of 
the  brain,  the  symptoms  produced  being  characteristic  of 
diseases  of  the  particular  organ  or  structure  involved.  A 
peculiar  sweetish  odor  is  emitted  from  the  perspiring  skin 
and  is  noticeable  in  the  breath.  This  is  observed  in  no  other 
condition,  and  is  sui^posed  to  be  pathognomonic. 

The  general  symptoms  found  in  the  second  stage  are 
more  pronounced.  Hyperesthesia  and  restlessness  are 
marked.  Sweating  is  extensive.  Skin  eruptions  are  com- 
mon, but  there  is  no  uniformity  in  their  appearance.  The 
mouth  especially  has  characteristic  signs.  The  tongue  is 
dry,  brown  and  heavily  coated,  and  sordes  accumulate  over 
the  teeth  and  gums.  Subsultus  tendinum  or  the  twitching 
of  the  muscles,  so  common  in  typhoid  and  the  infective 
fevers,  is  also  seen  in  pyemia. 

Post-mortem  examination  shows  that  abscesses  are  usu- 
ally numerous.  When  an  embolus  has  been  washed  away 
from  a  thrombus  plugging  a  vessel,  the  resulting  infarction 
will  become  necrotic  or  will  sujopurate.  Joints  are  found 
filled  with  pus.  The  liver,  spleen,  kidneys  and  lungs  are 
sometimes  studded  with  abscesses. 


22  NON-SPECIFIC    INFECTIONS 

Differential  Diagnosis.— Differential  diagnosis  must  be 
made  from  tuberculous  and  syphilitic  abscess  and  from 
acute  affections  of  bones,  joints,  and  glands  from  other 
causes. 

Treatment.— The  treatment  consists  in  incising  the  ab- 
scess, irrigating,  curetting  and  otherwise  sterilizing  the  ne- 
crotic tissues,  establishing  and  maintaining  drainage,  and 
repeating  the  cleansing  process.  The  constitutional  treat- 
ment is  the  same  as  that  given  for  septicemia. 


CHAPTER  III 


SPECIFIC    INFECTIONS 


ERYSIPELAS 


Erysipelas  is  an  acute  infection  of  the  skin  and  sub- 
dermal  structures.  In  all  forms  of  erysipelas  the  strepto- 
coccus erysipelatis  (Fehleisen),  which  produces  the  patho- 
logical change,  is  introduced  into  the  tissues  by  inoculation. 
This  may  be  done  by  some  instrument  or  during  an  injury 
caused  by  wood,  thorn,  nail,  etc.  In  the  facial  form  inocu- 
lation may  occur  in  the  mucous  membrane  of  the  lips  or 
anterior  nares. 

Pathology.— In  the  superficial  form  erysipelas  presents 
itself  as  a  dermatitis  of  scarlet  or  dark  red  color.  It  has 
a  tendency  to  travel  along  the  lymphatics.  The  erythema 
beginning  at  the  point  of  inoculation  extends  in  every  direc- 
tion, but  more  rapidly  toward  the  center  of  circulation.  The 
lymphatics  contain  cocci  and  are  hyperemic.  Phagocytosis 
goes  on  at  a  rapid  rate.  The  germs  are  rarely  found  in  the 
blood  vessels.  When  the  infection  is  confined  to  the  skin, 
suppuration  rarely,  if  ever,  occurs.  In  cellulitis,  or  when 
infection  extends  to  the  subdermal  structures,  suppuration 
is  the  rule.  Extensive  areas  may  be  suppurating  while  the 
skin  remains  intact.  Cellulitis  associated  with  an  amputa- 
tion of  a  leg  may  extend  up  to  the  next  joint,  but  seldom 
beyond  that  point.  The  skin  will  be  loose,  having  under- 
neath a  suppurating  area  with  pockets  between  the  muscles 
and  about  the  vessels  and  nerves. 

The   products    from   such   a   suppurating   surface   are 

23 


24  SPECIFIC    INFECTIONS 

highly  virulent,  and  the  surgeon  who  makes  the  dressing 
must  be  careful  that  he  has  no  abrasions  on  his  hands  or 
inoculation  will  result.  Erysipelas  patients  should  be  iso- 
lated from  all  other  cases,  and  one  who  has  the  care  of  them 
should  not  touch  a  clean  case  and  should  never  attend  an 
obstetric  case. 

Symptoms.— The  principal  evidence  in  the  superficial 
form  is  a  red  skin,  which  is  slightly  elevated  above  the  sur- 
rounding healthy  surface.  The  epithelia  are  enlarged  and 
the,  skin  is  slightly  roughened.  The  dilated  blood  vessels 
and  hemorrhagic  exudate  cause  the  change  in  color.  The 
margin  is  uniform  and  distinct,  although  it  may  be  irregu- 
lar. The  skin  pits  on  pressure,  caused  by  an  edematous 
condition.  The  serum  accumulates  between  the  epidermis 
and  derma  vera,  producing  vesicles  which  may  coalesce  and 
produce  patches  of  considerable  size.  They  rarely  become 
purulent.  The  serum  escapes  and  the  vesicles  collapse,  leav- 
ing a  crust,  which  eventually  desquamates.  The  most  char- 
acteristic symptom  is  the  tendency  to  spread. 

Constitutional  symptoms  resemble  those  in  septicemia. 
There  is  general  debility,  headache,  loss  of  appetite  and 
nausea,  followed  by  high  temperature.  Chill  is  not  always 
present.  The  temperature  is  remittent,  fluctuating  as  in- 
toxication is  increased  or  diminished.  In  facial  erysipelas 
the  symptoms  are  not  very  severe,  and  a  fatal  termination 
seldom  occurs.  In  phlegmonous  cellulitis  the  usual  symp- 
toms are  more  marked,  and  a  fatal  ending  is  not  uncommon. 
Septicemia  is  invariably  typically  developed  in  suppurative 
cases. 

When  erysipelas  extends  to  the  mucous  membrane  of  the 
mouth  and  tongue,  it  is  popularly  known  as  ''black  tongue." 
It  may  travel  along  the  nasal  cavity  to  the  pharynx  and 
into  the  stomach  and  produce  characteristic  symptoms,  or 
it  may  extend  into  the  lungs,  producing  pneumonia. 

Diagnosis.— This  condition  must  be  differentiated  from 
erythemas  caused  by  drugs,  and  from  the  eruptive  fevers, 


ERYSIPELAS  25 

and  also  from  the  redness  of  the  skin  associated  with  high 
temperature  in  continued  tyjDes  of  fevers. 

Prognosis.— In  facial  and  superficial  erysipelas  the  prog- 
nosis is  favorable,  and  in  many  cases  there  is  a  tendency 
to  spontaneous  recovery,  the  bacteria  apparently  having 
expended  their  force  and  died.  In  the  suppurative  form 
the  prognosis  is  grave,  and  unless  the  progress  of  the  dis- 
ease is  promptly  cut  short,  death  is  usually  the  result  in  a 
week  or  less. 

Treatment.— Isolation  is  the  first  step  in  treatment.  The 
nurse  who  assumes  immediate  charge  should  be  the  only 
person  to  touch  the  patient.  When  the  doctor  makes  an 
incision,  a  dressing  or  an  application,  he  should  immediately 
thereafter  cleanse  his  hands  and  boil  his  instruments,  or 
better,  never  use  the  latter  on  a  clean  case  again.  Dress- 
ings should  be  burned.  The  infections  are  of  a  most  power- 
ful and  insidious  character  and  too  much  care  cannot  be 
taken.  Medication  is  principally  local,  but  includes  consti- 
tutional treatment  as  well. 

Local  treatment  consists  of  the  use  of  germicides,  the 
principal  one  being  tincture  of  iodin.  In  the  local,  super- 
ficial and  facial  forms,  this  remedy  applied  over  the  red 
area  and  several  inches  beyond  will  usually  prevent  exten- 
sion of  the  disease,  destroying  the  activity  of  the  existing 
infection  as  well.  Tincture  of  iodin  should  be  applied  to 
the  skin  every  four  to  six  hours  for  forty-eight  hours,  not 
only  over  the  infected  skin,  but  for  several  inches  beyond 
the  line  of  demarcation.  Further  advance  of  the  infection 
may  thus  be  prevented.  Mercuric  chlorid  1  to  1,000  and 
carbolic  acid  1  to  30  are  in  constant  use.  Ichthyol  has  been 
used  to  control  the  activity  of  the  disease.  Heat  and  cold 
act  here  as  in  other  infections  and  are  of  undoubted  value. 
In  suppuration,  incisions  should  be  made  into  every  pocket 
and  the  parts  thoroughly  mopped  out  with  tincture  of  iodin 
or  irrigated  with  a  solution  1  to  3,000  of  mercuric  chlorid. 

Constitutional  treatment  should  include  all  the  remedies 


26  SPECIFIC    INFECTIONS 

required  to  stimulate  the  excretory  functions.  The  kid- 
neys, bowels  and  skin  should  be  made  active  to  eliminate 
toxins.  Nourishment  is  of  great  importance  and  concen- 
trated foods,  such  as  milk,  beef  tea  and  artificial  foods 
should  be  given  as  freely  as  they  can  be  taken.  Stimula- 
tion with  ammonia  and  strychnia  helps  to  carry  the  patient 
over  the  disease.  Tincture  of  iron  given  in  large  doses,  fif- 
teen to  twenty  minims  every  two  or  three  hours,  is  of  spe- 
cial value  as  a  supporting  tonic,  and  is  thought  by  some  to 
have  a  specific  action,  particularly  in  facial  erysipelas. 

ACTINOMYCOSIS 

Actinomycosis  is  a  very  rare  destructive  disease  of  men 
and  the  lower  animals.  It  is  most  frequently  seen  in  cattle 
and  is  then  called  "lumpy  jaw."  It  is  due  to  a  microorgan- 
ism belonging  to  the  ray  fungus  group.  It  runs  a  subacute 
course  with  gradual  involvement  of  adjacent  tissues  until 
life  is  destroyed.  It  is  accompanied  by  abscess  formation, 
the  bone  involved  increasing  in  size  as  a  result  of  general 
infiltration  of  the  growing  fungus.  A  macroscopic  examina- 
tion presents  a  suppurating  mass  studded  with  yellowish, 
gritty  particles  not  found  in  any  other  condition.  It  resem- 
bles sarcoma  in  some  respects  and  is  frequently  confused 
with  that  condition.  Throughout  the  mass  are  found  ab- 
scess cavities  varying  in  size.  When  it  involves  the  skin, 
pus  escapes  tiirough  many  points.  Untreated,  the  infection 
extends  to  adjacent  parts  and  to  the  viscera,  the  lungs  being 
most  frequently  attacked,  when  the  sputum  will  contain  the 
gritty  calcareous  particles.  Almost  every  tissue  of  the  body 
and  bone  of  the  skeleton  may  be  involved  before  death 
arrives. 

This  disease  must  be  differentiated  from  sarcoma,  syphi- 
lis, and  tuberculosis.  When  the  disease  is  suspected,  these 
conditions  should  be  excluded  by  making  a  thorough  study 
of  the  patient's  symptoms.    The  absence  of  the  night  pain 


ACTINO^^OrCOSIS 


27 


of  syphilis  and  the  acute  pain  of  sarcoma  will  do  much  to 
exclude  these  conditions,  since  there  is  little,  if  any,  jDain, 
and  constitutional  symptoms  are  not  marked. 

Treatment. — Treatment  consists  in  complete  extirpation 
of  the  disease.    If  in  the  skin,  it  should  be  cut  away,  along 


Fig.  1. — Actinomycosis.     (Dr.  J.  J.  Buchanan.) 

with  the  adjacent  areolar  tissue.  If  in  the  mandible,  suf- 
ficient of  the  bone  must  be  resected  to  include  healthy  tissue 
on  both  sides,  even  to  comjDlete  enucleation.  The  tongue 
may  be  amputated  beyond  the  point  of  infection.  In  all  of 
these  conditions  promise  of  non-return  can  be  made  if  ex- 
tirpation has  been  thorough.  AVlien  the  deeper  lymphatics, 
the  viscera  or  bones  of  the  skeleton  are  involved,  operation 
is  useless  except  as  a  palliative  measure. 


28  SPECIFIC    INFECTIONS 

Illustrative  Case.— The  accompanying  illustration  shows 
a  case  of  a  man,  aged  about  fifty,  who  was  a  saddler.  He 
was  thought  to  have  been  inoculated  through  the  cavity 
after  a  tooth  extraction.  He  had  a  habit  of  chewing  straws 
which  he  picked  up  about  his  saddlery  shop,  and  which  may 
have  been  in  the  mouth  of  a  horse  or  cow  suffering  with  the 
same  disease. 

TETANUS 

This  is  a  general  disease,  a  result  of  the  infection  of  a 
wound  by  a  specific  microorganism  (the  bacillus  tetani), 
and  is  characterized  by  tonic  contractions  of  one  or  several 
groups  of  muscles,  with  periodic  exacerbations. 

Etiology.— The  bacillus  of  tetanus  is  slender  and  rod- 
shaped.  Each  of  the  bacilli  forms  a  single,  large-sized 
spore,  usually  at  one  end,  giving  to  the  organism  the  ap- 
pearance of  a  drumstick.  These  spores  are  very  resistant 
to  chemical  germicidal  agents  and  to  conditions  of  dryness. 
They  are  even  able  to  survive  boiling  for  five  minutes. 

The  organism  is  a  perfect  anaerobe,  is  very  widely  dis- 
tributed in  nature,  and  is  easily  found  in  manure  and  stable 
refuse,  and  in  garden  earth.  It  may  often  be  obtained,  also, 
in  pus  from  the  wound  of  infection  in  patients  who  have  the 
disease,  but  it  does  not  invade  the  body  generally.  Such 
wounds  are  usually  small,  unhealthy,  and  lined  with  necrotic 
tissue  from  which  the  bacillus  may  be  isolated,  as  well  as 
other  organisms  (pyogenic  or  putrefactive)  with  which  it  is 
usually  associated. 

Symptoms.— The  symptoms  are  a  stiffness  in  the  mus- 
cles of  the  lower  jaw  and  neck,  difficulty  in  swallowing,  and 
occasionally  stiffness  of  muscles  of  other  parts  of  the  body. 
The  condition  develops  rapidly  with  a  sudden  rise  of  tem- 
perature, retention  of  urine,  profuse  sweating,  especially 
as  convulsions  develop,  and  extreme  pain  in  the  parts  in- 
volved. There  is  distortion  of  the  muscles  of  expression 
and  drooping  of  the  eyelids.    The  symptoms  are  fully  de- 


HYDROPHOBIA  29 

ve]oi3ed  in  twenty-four  hours  and  terminate  fatally  in 
forty-eight  hours.  Differential  diagnosis  must  be  made 
from  strychnia  poisoning. 

Treatment.— The  treatment  includes  the  introduction  of 
anti-tetanic  serum,  cleansing  of  the  wound  with  antiseptics, 
and  the  administration  of  diaphoretics  and  cathartics. 

HYDROPHOBIA 

Hydrophobia  is  an  acute  infective  disease  following  the 
bite  of  a  rabid  animal.  The  analogies  existing  between 
hydrophobia  and  other  diseases  of  undoubted  bacterial 
origin  justify  the  belief  that  this  disease  is  due  to  a  specific 
organism,  although  this  has  not  yet  been  demonstrated. 
The  disease  usually  follows  the  bite  of  a  dog.  The  virus 
appears  to  be  communicated  through  the  saliva  of  the  ani- 
mal, and  the  disease  is  most  likely  to  develop  when  the 
patient  is  infected  on  the  face  or  some  other  uncovered 
part.  Only  about  one  person  out  of  three  bitten  by  animals 
proved  to  be  rabid  suffers  with  the  disease.  The  inocula- 
tion period  averages  about  forty  days,  but  may  vary  from 
a  fortnight  to  eight  months. 

Symptoms.— The  symptoms  are  general  malaise,  chills 
and  giddiness,  with  involvement  of  the  muscles  of  degluti- 
tion and  respiration.  There  is  a  sudden  catch  in  the  breath- 
ing due  to  a  spasm  of  the  diaphragm.  Occasionally  there 
is  a  hiccough,  which  is  considered  by  the  laity  to  resemble 
the  bark  of  a  dog.  There  is  also  inability  to  swallow  food. 
The  temperature  is  elevated,  pulse  very  rapid  and  intermit- 
tent.   The  urine  may  contain  sugar  and  albumin. 

Prophylaxis.— The  bite  of  an  animal  suspected  of  being 
rabid  should  be  cauterized  at  once  by  means  of  the  actual  or 
Paquelin  cautery,  or  by  a  strong  chemical  escharotic,  such 
as  pure  phenol,  after  which  antiseptic  dressings  are  applied. 
It  is,  however,  to  Pasteur's  preventive  inoculation  that  we 
must  look  for  our  best  hope  of  averting  the  onset  of  symp- 


30  SPECIFIC    INFECTIONS 

toms.  "It  may  now  be  taken  as  established  that  a  grave 
responsibility  rests  on  those  concerned  if  a  person  bitten 
by  a  mad  animal  is  not  subjected  to  the  Pasteur  treatment" 
(Muir  and  Ritchie). 

Treatment.— When  the  symptoms  have  once  developed, 
they  can  only  be  palliated.  The  patient  must  be  kept  abso- 
lutely quiet  and  free  from  all  sources  of  irritation.  The 
spasms  may  be  diminished  by  means  of  chloral  and  bro- 
mids,  or  by  chloroform  inhalation.  There  is  great  difficulty 
in  feeding  the  patient,  and  administration  may  necessarily 
be  by  the  rectum. 

ANTHRAX 

Anthrax,  sometimes  called  malignant  pustule,  is  an  acute 
infectious  disease  caused  by  an  infection  by  the  anthrax 
bacillus,  a  rod-shaped  organism,  forming  spores  on  the  out- 
side of  the  animal  body.  It  attacks  both  animals  and  man, 
but  most  frequently  the  domestic  herbivora.  It  is  trans- 
mitted from  animal  to  man  by  inoculation,  by  respiration 
and  through  the  food.  It  is  also  thought  to  be  transmitted 
by  flies. 

The  period  of  incubation  is  from  three  to  six  days.  The 
pustule  develops  on  the  skin  as  a  vesicle  containing  a  pink- 
ish to  blue  fluid,  swelling  with  a  purplish  or  reddish  base 
to  the  ulcer.  The  vesicle  bursts  and  a  crust  is  formed  as 
a  result  of  the  drying  of  the  secretion.  The  ulcer  varies 
from  the  size  of  a  pea  to  that  of  a  ten-cent  piece.  The 
swelling  and  redness  extend  into  the  various  parts  of  the 
skin.  There  is  burning,  itching  and  tenderness.  The  dis- 
ease extends  to  the  lymphatic  glands  and  may  extend  to 
the  deeper  structures  of  the  body,  such  as  the  abdominal 
viscera  or  the  lungs,  resulting  fatally. 

Diagnosis.— Diagnosis  is  based  upon  an  examination  of 
some  part  of  the  ulcer  and  the  discovery  of  the  anthrax 
bacillus. 


ANTHRAX  31 

Treatment.— The  treatment  consists  in  the  administra- 
tion of  Sclavo's  serum.  Snhdermal  injections  of  phenol 
and  other  antiseptics  have  yielded  satisfactory  results. 

Other  specific  infections,  which  are  of  little  interest  to 
the  dentist,  are  glanders  and  leprosy.  They  will  not  be  con- 
sidered here. 


CHAPTER  JV 


GE]SrEEAL    TUBERCULOSIS 


Tuberculosis  is  an  infective  inflammation  dependent 
upon  the  action  of  the  bacillus  of  tuberculosis.  It  is  the 
most  frequent  of  all  diseases,  destroying  more  lives  every 
year  than  any  other  infection,  the  number  being  estimated 
at  about  twenty-five  per  cent,  of  the  total  number  of  deaths 
from  all  causes.  Its  ravages  attack  every  tissue  in  the  body 
of  man  and  in  many  of  the  lower  animals.  Its  most  common 
form  is  tuberculous  phthisis.  Next  in  frequency  it  attacks 
the  skeleton,  principally  of  children,  in  the  form  of  hip, 
knee  and  other  joint  diseases,  and  spondylitis,  or  Potts' 
disease  of  the  spine.  The  skin  is  a  common  seat  of  destruc- 
tion, showing  the  disease  in  the  form  of  lupus  and  other 
ulcerations.  All  of  the  conditions  formerly  called  scrofu- 
lous are  now  considered  either  syphilitic  or  tuberculous. 

Etiology.— The  etiological  features  are:  (a)  Injury  of  a 
slight  nature;  (b)  introduction  of  the  bacillus  in  the  area  of 
injury;  (c)  reduced  resistance  as  result  of  previous  sickness 
or  dissipation;  (d)  predisi30sition  of  heredity. 

The  bacilli  of  tuberculosis  are  rod-shaped  organisms, 
often  occurring  in  pairs,  arranged  end  to  end,  but  not  at- 
tached. The  bacillus  may  appear  straight  or  more  or  less 
curved  and  may  branch.  It  is  found  in  man,  cattle  and 
fowl,  and  is  the  specific  cause  of  tuberculosis  in  its  various 
forms.  The  organism  may  be  said  to  occur  in  two  forms, 
"human"  (which  is  described  above)  and  a  bovine  bacillus. 
The  latter  is  shorter  and  thicker  than  the  human  germ,  and 
does  not  exhibit  the  curved  or  branching  form  which  is  com- 
mon in  the  human. 

32 


PATHOLOGY  33 

The  organism  multiplies  only  in  the  body  and  excreta 
of  tuberculous  individuals.  The  sputa  or  other  excreta 
containing  the  bacillus  may  dry  and  retain  the  bacillus  in 
a  dormant  state  which  is  still  potential.  The  bacillus  is  also 
found  in  the  lesions  in  all  parts  of  the  body. 

Avenues  of  entrance. — Infection  occurs  by  introduction 
into  the  blood  by  one  of  the  following  routes:  (a)  From 
ulcerating  tonsils;  (b)  through  the  lungs;  (c)  from  the 
mouth  or  alimentary  tract ;  (d)  through  wounds  of  the  skin ; 
(e)  secondary  to  other  foci  in  the  lungs,  glands,  etc.  Prob- 
ably bacilli  are  in  the  blood  of  healthy  individuals  at  all 
times. 

Pathology.— A  typical  tubercle  is  a  non- vascular,  gray- 
ish neoplasm,  composed  of:  (a)  a  giant  cell  in  the  center, 
surrounded  by  (b)  epithelial  area  upon  the  periphery  of 
which  are  found  (c)  leucocytes  or  small  round  cells,  all  of 
which  are  held  by  (d)  reticulum.  The  giant  cell  may  be 
absent  and  it  may  also  be  found  in  bone  marrow,  granula- 
tion tissue,  sarcoma,  gummata,  etc.  The  epithelial  cells 
may  become  caseous  in  the  process  of  healing,  or  as  fibro- 
blasts they  may  be  converted  into  fibrous  tissue.  Leuco- 
cytes are  found  at  the  periphery,  outlining  the  field  of  in- 
vasion, and  are  barriers  set  up  to  prevent  extension  of  the 
disease  into  surrounding  healthy  tissue. 

Bacilli  are  found  principally  in  the  giant  cell  and  are 
projected  into  the  epithelial  area,  but  are  never  found  in 
the  leucocytic  zone.  A  tubercle,  being  without  vessels,  soon 
begins  to  degenerate  at  the  giant  cell,  becoming  fatty,  ne- 
crotic, caseous,  calcareous,  or  liquefying,  forming  a  ''cold 
abscess."  Several  tubercles  may  undergo  the  same  changes 
simultaneously  or  successively  and  coalesce,  forming  a  mass 
of  considerable  size.  The  course  is  essentially  chronic,  but 
it  may  be  subacute,  and  rarely  it  is  acute.  In  bone  disease 
the  course  of  destruction  and  repair  has  been  kno^\Ti  to 
extend  over  one  to  two  decades  without  at  any  time  endan- 
gering life.     Tuberculous  glands  may  remain  enlarged  for 


34  GENEKAL    TUBERCULOSIS 

many  years,  and  periodically,  as  at  certain  seasons,  the 
process  may  become  active.  The  jorimary  focus  may  be  in 
any  structure,  and  secondary  or  many  foci  may  develoj) 
in  other  tissues  in  any  part  of  the  body  remote  from  the 
original  infection.  The  primary  focus  is  usually  circular 
and  the  secondary  usually  triangular  or  conical,  or  an  in- 
farction. 

So  positively  has  its  infectibility  been  established  that 
those  afflicted  with  lung  infection  are  isolated  as  are  cases 
of  smallpox,  scarlatina,  cholera,  etc. 

Frequent  seats  of  tuberculosis  are  the  lungs,  lymjDhatic 
glands,  bones  and  joints,  mucous  membranes  of  larynx  and 
intestines,  serous  membranes,  prostate,  testicle,  ovaries. 
Fallopian  tubes,  kidneys,  uterus,  suprarenal  capsules,  brain, 
liver  and  spleen.  In  some  of  the  latter  sites  it  is  usually 
secondary. 

According  to  Park,  the  following  fates  await  a  miliary 
tubercle:  (a)  absorption;  (b)  encapsulation;  (c)  cheesy  de- 
generation; (d)  calcareous  degeneration;  (e)  suppuration. 

Treatment  of  Tuberculosis.— General  treatment  does  not 
differ  from  that  outlined  for  tuberculosis  of  the  lungs.  Out- 
door life  in  pure  air  is  the  first  and  principal  step  in  treat- 
ment. Air  of  the  mountains  and  the  sea  contains  no  germs. 
In  densely  populated  cities  the  air  contains  every  variety 
of  bacterium.  Forced  feeding  with  concentrated  foods, 
such  as  milk  and  raw  eggs,  should  be  faithfully  carried  out. 
From  a  quart  to  a  gallon  of  milk  and  from  three  to  ten  raw 
eggs  daily  are  not  uncommonly  tolerated  by  these  patients. 

Repair  is  from  within  or  from  the  blood,  and  when  its 
richness  can  be  increased,  the  protoplasmic  cells  found  in 
the  zone  of  invasion  have  a  greater  resistance,  hence  the 
bacilli  which  are  advancing  into  newer  areas  to  destroy 
tissues  are  checked. 


CHAPTER  V 


THE    VENEREAL    DISEASES 


The  venereal  diseases  are  contagious  affections  usually 
transmitted  during  sexual  intercourse,  but  they  may  be 
acquired  innocently  when  some  intermediate  object  serves 
as  the  carrier  of  the  virus. 

The  three  venereal  diseases  are  gonorrhea,  chancroid, 
and  syphilis. 

GONORRHEA 

Gonorrhea,  in  the  male,  is  an  intense  urethral  inflamma- 
tion developing  in  from  three  to  ten  days  after  infection  by 
the  specific  organism  (the  gonococcus  or  diplococcus  of 
Neisser)  and  characterized  by  a  profuse  discharge.  It  is 
the  most  frequent  of  the  venereal  diseases  and  is  essentially 
of  sexual  origin.  Other  mucous  membranes  are  susceptible 
to  the  infection — the  eye,  rectum  and  anus.  Cases  have 
been  reported  of  gonorrheal  infection  of  the  mouth  and 
nose,  but  proof  is  not  conclusive  that  these  mucous  mem- 
branes are  susceptible  to  infection  by  the  gonococcus. 

The  urethra  is  the  primary  site  of  the  infection  in  the 
male,  and  the  disease  may  extend  to  the  bladder,  ascending 
by  the  ureters  to  the  kidneys  (very  rarely),  or  may  involve 
the  sexual  organs — the  prostate,  seminal  vesicles,  the  vasa, 
epididymes  and  testes.  In  the  female  the  vaginal  and  cer- 
vical mucous  membranes  are  affected.  The  disease  may  in- 
volve the  urethra  and  bladder.  When  it  spreads  to  the 
uterus,  tubes  and  ovaries,  it  becomes  a  serious  affection 
and  often  it  is  not  curable  except  by  removal  of  the  diseased 

35 


36  THE   VENEREAL   DISEASES 

organs  by  operation.  Gonorrhea  is  responsible  for  a  large 
percentage  of  the  sterility  in  women  and  necessitates  a 
majority  of  the  operation^  done  upon  the  female  sexual 
organs. 

Complications. — The  complications  which  may  arise 
during  the  course  of  gonorrhea  are  balanitis,  phimosis, 
paraphimosis,  folliculitis,  urethral  fistula,  Cowperitis,  pros- 
tatitis, vesiculitis,  epididymitis,  orchitis,  and  urethro-cysti- 
tis.  Enlargement  of  the  inguinal  glands  (bubo)  occasion- 
ally occurs  (especially  in  the  uncleanly),  but  seldom  pro- 
gresses to  su]3puration.  Stricture  of  the  urethra  results 
from  the  long  continuance  of  gonorrhea.  Systematic  in- 
fection is  manifested  by  involvement  of  the  joints,  muscles, 
tendon  sheaths  and  bursse.  From  the  dentist's  standpoint, 
gonorrheal  arthritis  of  the  temporo-maxillary  articulation, 
producing  ankylosis,  is  of  interest. 

Gleet  is  the  term  applied  to  a  chronic  muco-purulent  dis- 
charge produced  in  certain  localized  areas  of  the  mucous 
membrane  of  the  urethra  which  have  not  healed.  A  gleety 
discharge  is  contagious  if  it  contains  the  gonococcus. 

Chronic  gonorrhea  is  usually  due  to  one  or  other  of  its 
complications.  The  gonococcus  may  remain  latent,  giving 
no  symptoms  which  manifest  its  presence  for  years,  and 
again  start  up  acute  inflammation  or  be  transmitted  to  an- 
other and  produce  a  virulent  infection. 

Treatment.— The  treatment  of  acute  gonorrhea  consists 
of  cleanliness,  rest,  the  administration  of  urinary  antisep- 
tics and  balsamics,  the  injection  into  the  urethra  of  remedies 
which  will  inhibit  the  growth  of  the  gonococcus  (especially 
the  organic  silver  salts — argyrol,  protargol,  etc.)  and  irri- 
gation of  the  urethra  by  the  Janet  method.  In  chronic  gon- 
orrhea, irrigations,  instillations  and  the  use  of  sounds  and 
dilators  are  called  for.  Thorough  treatment  of  the  acute 
disease  to  prevent  its  extension  backward  along  the  urethral 
canal  should  always  be  undertaken  to  insure  early  recovery 
and  prevent  the  serious  complications  which  involve  the 


SYPHILIS  37 

integrity  of  the  sexual  organs  and  tlie  possibility  of  latent 
infection. 

CHANCROID 

The  chancroid  (or  soft  chancre)  is  a  local  contagious 
venereal  ulcer  caused  by  the  bacillus  of  Ducrey.  It  has  no 
period  of  incubation,  but  clinically  it  manifests  itself  about 
the  third  day  after  inoculation.  It  is  rarely  acquired  except 
by  intercourse.  It  is  most  commonly  seen  in  hospital  prac- 
tice because  of  the  uncleanly  and  careless  habits  of  these 
patients.  The  pus  from  the  sore  is  capable  of  almost  in- 
definite auto-inoculation,  and,  as  a  result,  the  lesions  are 
usually  multiple. 

It  begins  as  a  pustule  or  ulcer.  The  edges  of  the  ulcer 
are  ragged,  punched-out  or  undermined  and  surrounded  by 
an  inflammatory  areola.  The  discharge  is  free,  thick  and 
creamy.  The  floor  is  rough  and  uneven  (worm-eaten). 
There  may  be  a  thick  moist  scab.  The  base  of  the  sore  is 
soft  and  pliable  from  inflammatory  edema  (not  indurated). 

Adenitis  or  inflammatory  bubo  is  a  frequent  complica- 
tion. The  inguinal  glands  are  involved  when  the  lesion  is 
genital,  that  is,  the  glands  in  closest  anatomical  relation — 
to  which  the  lymph  vessels  leading  from  the  infected  area 
lead.  The  adenitis  is  usually  unilateral.  A  hard,  tender 
lump  develops,  which  increases  in  size  and  becomes  adherent 
to  the  overlying  skin.  Fluctuation  develops,  and  unless  the 
lump  is  incised  it  ultimately  ruptures. 

Treatment.— Treatment  consists  in  surgical  cleanliness 
and  the  use  of  mild  antiseptics  or  cauterizing.  Antiseptic 
powders  may  be  used  when  the  discharge  is  not  profuse. 
Wet  dressings  are  indicated  when  the  secretion  is  profuse. 
The  suppurating  bubo  should  be  incised,  disinfected,  and 
treated  as  an  abscess. 

SYPHILIS 

Syphilis  is  a  specific  constitutional  disease  transmitted 
by  heredity  or  acquired  by  infection.    In  the  acquired  form 


38  THE   VENEREAL   DISEASES 

it  is  characterized  by  the  appearance,  at  the  point  of  inocu- 
lation, of  a  primary  lesion,  followed  in  the  usual  course  by 
eruptive  lesions  of  the  skin  and  mucous  membranes,  and 
may  ultimately  produce  symptoms  involving  one  or  many 
of  the  organs  of  the  body. 

In  1903,  Metchnikoff  and  Eoux  successfully  inoculated 
anthropoid  apes.  The  disease  can  be  transferred  from  one 
animal  to  another,  and  each  is  immune  to  further  inocula- 
tion. 

In  1905,  Schaudinn  and  Hoffman  demonstrated  a  micro- 
organism (the  Spirochgeta  or  Treponema  Pallida)  to  be  of 
constant  occurrence  in  syphilitic  lesions.  Their  claim  that 
it  is  the  specific  infecting  organism  has  since  been  abun- 
dantly verified.  The  spirocheta  is  an  extremely  delicate 
thread  twisted  in  a  spiral  form.  The  spirals  are  of  uniform 
width  and  depth.  Their  ends  are  sharp  and  tapering.  They 
are  four  to  ten  microns  in  length.  (The  red  blood  corpus- 
cles are  7.9  to  9.3  microns.)  They  are  mobile  organisms 
cajDable  of  progression,  rotation  and  bending  and  twisting. 
Dr.  Noguchi  has  recently  succeeded  in  growing  the  Spiro- 
chetes on  artificial  media.  They  lose  their  virulence  when 
heated  to  51°  C.  for  one  hour  or  to  60°  C.  for  one-half  hour. 
Secretions  containing  the  spirocheta  soon  become  innocu- 
ous. The  spirocheta  is  found  in  the  secretions  from  chan- 
cres and  mucous  patches,  in  the  enlarged  glands,  in  the  skin 
lesions,  in  the  blood  (several  positive  findings  reported), 
and  in  nearly  all  the  organs  and  tissues,  secretions  and  ex- 
cretions of  the  congenitally  syphilitic.  The  semen  of  a 
syphilitic  in  the  secondary  stage  has  produced  the  disease 
in  an  inoculated  monkey,  but  in  others  of  the  normal  secre- 
tions in  the  acquired  form  of  the  disease  the  search  for  the 
spirocheta  has  been  negative. 

Cover  glass  i^reparations  can  be  stained  by  various 
methods  to  show  the  spirocheta  and  by  the  use  of  dark  field 
illumination  it  can  be  seen  through  the  microscope  in  its  liv- 
ing state  and  its  movements  observed. 


SYPHILIS  39 

The  Wassermann  reaction  is  a  blood  test  which  can  be 
made  only  by  competent  laboratory  workers.  Its  technique 
does  not  concern  us.  The  specificity  of  this  reaction  has 
been  questioned,  but  a  positive  result  is  obtained  in  a  large 
majority  of  syphilitic  patients.  In  the  absence  of  symptoms 
this  test  may  give  evidence  of  the  presence  of  the  disease 
and  throw  light  ujDon  many  obscure  conditions  of  doubtful 
etiology.  It  is  being  used  largely  as  evidence  of  the  result 
of  treatment  or  test  of  cure. 

Modes  of  Contagion.— There  are  four  modes  of  conta- 
gion :  Direct — by  contact  of  an  abraded  surface  with  an  in- 
fectious lesion  of  a  diseased  person,  as  in  intercourse,  kiss- 
ing, etc. ;  mediate — when  some  intermediate  object  serves  as 
the  carrier  (for  this  reason  all  instruments  used  should 
be  thoroughly  sterilized,  preferably  by  boiling,  before  being 
again  used,  and  dental  instruments  which  cannot  be  boiled 
should  be  discarded) ;  inheritance  from  one  parent  or  both; 
Choc-en-retour ,  syphilis  by  conception,  the  infection  of  a 
mother  conceiving  to  a  syphilitic  father.  She  is  infected 
through  the  placental  circulation  and  does  not  manifest  the 
primary  lesion. 

According  to  Colles'  law,  a  child  begotten  by  a  syphilitic 
father  and  born  of  an  apparently  healthy  mother  cannot 
infect  her.  Such  a  mother  is  immune  to  infection  from  be- 
ing herself  syphilitic  (latent),  or  the  toxins  absorbed  from 
the  infected  fetus  may  stimulate  in  such  a  mother  the  for- 
mation of  immunizing  bodies.  The  majority  of  such  moth- 
ers give  a  positive  Wassermann  blood  test. 

The  Stages  of  Syphilis.— There  are  six  stages  of  syphilis, 
as  follows :  1.  Priynary  incubation,  the  time  between  expos- 
ure and  the  appearance  of  the  primary  lesion,  averaging 
about  twenty-one  days,  and  varying  from  two  weeks  to 
forty  days  or  more.  2.  The  period  of  primary  symptoms, 
the  time  of  development  of  the  chancre  and  its  associated 
adenitis.  3.  Secondary  incuhation  period,  or  the  time 
elapsing  from  the  appearance  of  the  primary  lesion  until 


40  THE   VENEREAL   DISEASES 

the  occurrence  of  the  secondary  symptoms,  of  an  average 
duration  of  six  weeks.  4,  Period  of  secondary  symptoms, 
during  which  the  disease  is  manifested  by  fever,  anemia, 
neuralgic  pains,  alopecia,  and  the  superficial  syphilides  of 
the  skin  and  mucous  membranes.  5.  Intermediate  period, 
or  the  time  of  freedom  from  symptoms  between  the  secon- 
dary and  tertiary  stages.  Tertiary  lesions  may  follow  di- 
rectly upon  the  secondaries,  or  they  may  never  develop. 
6.  Period  of  tertiary  symptoms,  characterized  by  the  de- 
velopment of  gumma  or  gummatous  infiltrations  of  various 
organs  and  structures. 

The  Primary  Lesion.— The  chancre  (initial  lesion  or 
sclerosis,  hard  or  infecting  chancre,  indurated  neoplasm, 
Hunterian  chancre)  is  the  lesion  occurring  as  the  first  man- 
ifestation of  the  syphilitic  x^oison  at  its  point  of  entrance 
into  the  body  (at  the  site  of  inoculation).  It  may  be  on 
any  j)art  of  the  body — genital  or  extragenital  (elsewhere 
than  on  or  near  the  genital  organs).  It  usually  develops 
about  the  twenty-first  day  after  exposure.  Induration  is 
its  most  characteristic  feature.  It  consists  of  a  sharply  cir- 
cumscribed hardening  due  to  cellular  infiltration  of  the 
tissues  beneath  the  lesion  and  extending  wide  of  its  margins. 
The  induration  is  best  palpated  by  iDinching,  with  the  fingers 
placed  beyond  (or  wide  of)  the  superficial  margins  of  the 
sore.  It  develops  in  from  five  to  ten  days  after  the  appear- 
ance of  the  chancre  and  is  at  its  maximum  in  about  two 
weeks.  An  adenitis  (bubo)  of  the  anatomically  associated 
lymph  glands  (to  which  the  lymph  vessels  draining  the  area 
of  the  lesion  joass)  develops  usually  by  the  tenth  day.  A 
number  of  glands  are  usually  easily  palpable.  Each  gland 
is  felt  as  a  rounded,  smooth,  hard  nodule,  freely  movable 
beneath  the  skin.  The  glands  may  be  slightly  sensitive, 
but  are  not  acutely  inflamed  and  do  not  suppurate. 

The  chancrous  erosion  is  the  commonest  form  of  the 
initial  lesion  (75  per  cent,  of  all).  The  epidermis  is  exfo- 
liated, and  the  true  skin  exposed  but  not  destroyed  (not  an 


SYPHILIS  41 

ulceration).  The  surface  is  polished,  eroded,  or  raw-look- 
ing, and  a  gray,  false  membrane  may  cover  its  central  part. 
It  may  be  level  with  the  surrounding  surface  or  may  be 
slightly  elevated.  A  red  areola  surrounds  the  lesion.  The 
discharge  is  scanty  and  serous  or  sero-purulent.  The  Hun- 
terian  chancre  or  cliancrous  ulceration  is  a  crater-like  or 
funnel-shaped  excavation.  The  edges  are  not  abrupt, 
punched-out  or  undermined,  but  slope  gradually  towards 
the  center.  Other  forms  (indurated  papule,  silvery  spot, 
herpetiform  chancre)  are  less  common  than  these  forms  and 
only  occasionally  seen.  A  chancre  may  heal  before  the 
secondary  symptoms  appear  or  may  persist  as  an  indurated 
area  for  months  afterward. 

In  the  oral  cavity  the  initial  lesion  may  occur  on  the 
lips,  the  tongue,  the  mucous  membrane  of  the  buccal  cavity, 
the  palatal  arches,  and  the  tonsils.  The  lymph  glands 
(submental  and  submaxillary)  become  enlarged  within  the 
second  week  and  are  usually  sensitive  and  give  some  dis- 
comfort. A  chancre  of  the  lip  is  usually  a  large,  j)rominent, 
indurated  nodule,  with  eroded  raw  surface  on  the  vermil- 
ion border,  commonly  quite  painful.  A  chancre  of  the 
tongue  is  usually  seen  on  the  dorsum  or  anterior  portion 
of  the  border.  It  is  likely  to  be  quite  large,  and  the  sur- 
rounding tissues  may  be  infiltrated  widely  by  the  lym- 
phangitis. Induration  is  of  cartilaginous  hardness  and 
subhyoid  adenitis  develops.  Chancre  of  the  gum  is  exceed- 
ingly rare.  When  occurring  on  the  tonsil,  it  is  likely  to 
be  mistaken  at  first  for  an  ordinary  sore  throat.  It  is, 
however,  unilateral.  The  tonsil  is  usually  swollen  and  its 
surface  flat,  eroded,  or  ulcerated.  Palpation  reveals 
marked  induration.  Adenitis  of  the  lateral  cervical  glands 
develops. 

Figure  2  shows  the  finger  of  a  dentist  who  had  been 
doing  considerable  extracting  for  some  time.  He  x)resented 
himself  to  the  author  with  a  small  eroded  sore  near  the 
nail  root.     This  lesion  increased  in  sjoite  of  local  treatment, 


42 


THE   VENEREAL  DISEASES 


until  a  typical  chancre  developed,  as  the  photograph  shows. 
The  patient  could  not  discover  the  source  of  the  infection. 
The  finger  was  evidently  inoculated  during  an  extraction, 
probably  having  been  injured  by  the  forceps  or  a  tooth, 
where  the  Spirochseta  pallida  was  present  in  the  mouth, 
either  in  the  blood  or  the  secretion  from  a  mucous  patch 
whose  presence  was  not  suspected.  Two  other  dentists  have 
come  under  observation,  similarly  inoculated. 


Fig.  2. — Initial  Lesion  on  the  Finger  op  a  Dentist. 

Diagnosis  of  chancre  is  based  upon  the  following  con- 
siderations : 

1.  Confrontation.     Examination  of  suspected  partner. 

2.  Incubation.  Chancre  develops  after  ten  days,  usu- 
ally about  the  twenty-first  day,  after  exposure.  It  may  be 
as  late  as  forty  days  or  more. 

3.  Character  of  lesion.  Seventy-five  per  cent,  are  ero- 
sions. 

4.  Induration.  One  of  its  best  diagnostic  features.  If 
sore  has  been  cauterized  a  similar  induration  may  develop. 

5.  Adenitis.    An  almost  constant  symptom. 

6.  Presence  of  Spiroch^ta  pallida.  Detected  by  micro- 
scope, by  dark  field  illuminator,  or  by  staining  methods. 


SYPHILIS  43 

7.  Secondary  symptoms.  Their  development  is  con- 
clusive iDroof. 

8.  Wassermann  reaction.  Not  always  present  before 
secondary  symptoms  develop. 

Secondary  Symptoms.— The  secondary  symptoms  are: 

Alterations  in  the  blood.  An  essential  anemia  in  nine- 
ty-five per  cent,  of  the  cases. 

Erythema  of  the  fauces.  The  soft  palate  and  pillars  of 
fauces  are  of  uniform,  dull  red  color.  A  sharp  line  of  de- 
marcation exists  between  healthy  and  affected  parts. 

General  glandular  enlargement.  Evidences  of  systemic 
infection.  The  lymph  glands  other  than  those  in  ana- 
tomical relationship  with  the  chancre  become  enlarged, 
firm,  hard,  freely  movable  under  the  skin,  and  are  painless. 
Pea  to  chestnut  in  size.  The  post-cervical,  epitrochlear, 
suboccipital,  supraclavicular,  submaxillary,  submental  and 
pectoral  can  be  palpated. 

Syphilitic  fever,  developing  a  week  or  ten  days  prior 
to  eruptions.    This  is  not  frequently  seen. 

Pains:  Headache,  neuralgia,  osteocopic  (bone-tearing) 
pains,  arthralgia  and  rheumatoid  pains. 

Alopecia.  Occurs  as  three  forms — complete,  patchy 
baldness  and  general  thinning  of  the  hair. 

The  syphilides  appear,  on  an  average,  about  six  weeks 
after  the  appearance  of  the  chancre. 

These  do  not  give  subjective  symptoms  (are  painless  and 
do  not  itch),  are  of  rounded  contour,  of  raw  ham  or  cojDper 
color,  and  the  early  eruptions  are  usually  symmetrical  and 
polymorphous  (several  forms  of  eruption  coexist). 

Forms  of  Syphilides  : 

1.  Erythematous  (Macular,  Eoseola). 

2.  Papular. 

a.  Acuminate.    Large.    Small. 

b.  Lenticular.    Large.    Small. 

c.  Moist  Papules  (mucous  patches). 

d.  Papulo  Squamous. 


44  THE   VENEREAL   DISEASES 

3.  Vesicular. 

4.  Pustular. 

a.  Small  Acuminate. 

b.  Large  Acuminate. 

c.  Small  Flat. 

d.  Large  Flat. 

5.  Pigmentary. 

6.  Bullous. 

7.  Tubercular. 

8.  Gummatous. 

The  commonest  form  of  tlie  secondary  skin  eruptions  is 
the  macular.  These  commence  as  irregular,  rose-red 
blotches  which  at  first  disappear  on  pressure,  but  later, 
when  pigTQentation  develops,  leave  a  brownish  stain.  They 
commence  on  the  sides  and  front  of  the  chest  and  abdomen 
and  extend  to  the  extremities.  They  are  rarely  seen  on  the 
face.  The  papular  syphilides  may  coexist.  These  latter, 
when  occurring  early,  are  symmetrical  and  generalized,  but 
are  grouped  on  limited  areas  when  occurring  late.  They 
vary  in  size  from  a  pin-head  to  one-half  inch  in  diameter 
and  from  light  crimson  to  a  dull  copper  color.  They  project 
above  the  skin  (elevations)  and  may  scale  at  the  top  or  be 
surrounded  by  a  collarette  of  scales.  They  are  firm  to  the 
touch,  and  the  surface  is  shiny. 

Tertiary  Symptoms.— Tertiary  manifestations  may  de- 
velop at  any  time,  even  years,  after  the  disappearance  of 
secondary  symptoms.  They  appear  as  infiltrations,  in- 
volve the  deeper  tissues  of  the  body,  as  the  visceral  and 
skeletal  systems,  and  are  destructive,  leaving  cicatricial  tis- 
sue. They  differ  from  secondary  lesions,  which  are  super- 
ficial, not  infiltrative  or  destructive  and  leave  slight  or  no 
scar. 

Tertiary  syphilides,  as  cutaneous  gummata  (syphilitic 
lupus),  are  circumscribed  infiltrations  of  the  skin,  involv- 
ing its  entire  thickness  and  projecting  above  its  surface. 
The  surface  is  flat  or  rounded  and  the  borders  are  sharply 


SYPHILIS  45 

defined.  When  tliey  disappear  by  resolution  pigmented 
cicatrices  remain;  bnt  when  ulceration  occurs  thick  scabs 
may  form  and  the  cicatrices  cause  disfigurement.  Subcu- 
taneous   gummata    (gummatous    syphilides)    are    circum- 


FiG.  3. — Macular  Syphiude.     The  early  eruption  of  secondary  sj^hilis. 

scribed  firm  nodules  developing  in  the  subcutaneous  con- 
nective tissue,  not  primarily  involving  the  skin,  which  is 
readily  movable  over  them.  At  first  they  are  appreciable 
to  the  touch  only,  but  they  increase  in  size,  producing  promi- 
nences, and  become  adherent  to  the  skin.  Syphilides  of  this 
character  often  extend  to  the  underlying  structures,  fascia, 
periosteum,  bone,  cartilage  and  tendons. 


46  THE   VENEREAL   DISEASES 

Gummata  appear  in  three  forms :  a  single  tnmor,  a 
group  of  nodules,  or  a  diffuse  infiltrated  patch.  A  gumma 
is  a  true  tumor  or  granuloma,  which  jDermanently  affects 
the  area  invaded,  whether  it  disappears  by  absorption  or 
ultimately  ulcerates,  as  is  its  tendency.  A  gumma  may 
take  weeks  or  months  to  develop  and  is  painless.  When  it 
reaches  its  full  size,  fluctuation  is  felt.    If  lanced,  a  gummy 


Fig.  4. — Syphilitic  Ulceration  of  the  Face  axd  Nose.     Most  characteristic 
of  tertiary  syphilis  in  neglected  cases.     (Dr.  Geo.  C.  Johnston.) 

puriform  substance  and  some  blood  exude.  Absorption  may 
then  occur  or  ulceration  may  take  place  from  central  soft- 
ening (coagulation  necrosis).  When  a  gumma  involves  the 
skin  and  ruptures  through,  there  is  no  abundant  discharge 
as  from  an  abscess,  but  the  content  is  adherent  by  its 
deeper  portions  to  the  subcutaneous  tissues,  and  is  thrown 
off  subsequently  in  the  form  of  sloughs.  The  ulcer  is 
sharply  defined,  punched  out  and  surrounded  by  a  dark, 
indurated  hyx3eremic  areola.    If,  in  the  cutaneous  gumma, 


SYPHILIS  47 

resolution  occurs  before  softening,  a  slightly  depressed  area 
of  nearly  normal  skin  remains.  If  softening  lias  occurred, 
the  depression  is  marked  and  the  skin  is  transformed  into 
scar  tissue.  When  ulceration  has  occurred  the  cicatrix  is 
depressed,  thin,  and  of  pearly  white  color,  and  when  the 
ulceration  has  been  deep  the  scars  are  much  depressed,  at 
first  pigTQented,  and  later  white  and  adherent  to  the  under- 
lying structures. 

Arthralgia  is  an  early  manifestation  in  the  joints.  Pain 
is  usually  worse  at  night.  Synovitis  (hydrarthrosis)  is  an 
early  symptom  of  syphilis  of  the  joints  and  may  be  either 
mono-  or  poly-articular.  There  is  no  febrile  disturbance, 
and  pain  is  not  severe.  Tertiary  arthritis  is  due  to  gum- 
mata  and  gummatous  infiltration  of  the  joint  structures, 
giving  impairment  of  motion,  muscular  atrophy,  and 
pain. 

In  syphilis  of  hones,  trauma  is  an  evident  etiological  fac- 
tor. The  facial  and  cranial  bones,  clavicle,  sternum,  tibia, 
and  ulna  are  favorite  seats  of  the  disease.  Pain  is  usually 
more  severe  at  night.  These  are  nearly  always  tertiary 
or  late  manifestations.  In  osteoperiostitis  there  occurs  a 
cellular  infiltration  on  the  deeper  layers  of  the  periosteum 
which  invades  the  bone  substance,  producing  elevations 
(nodes).  These  nodes  are  not  adherent  to  the  skin,  are  ten- 
der, elastic,  well-defined,  and  sensitive  to  pressure.  When 
more  than  one  node  develops  the  diagnosis  of  syphilis  is 
favored,  since  there  is  but  one  node  in  osteoma,  osteosar- 
coma, tuberculous  abscess,  and  other  affections.  Many 
bones  may  be  simultaneously  affected.  This  process  may 
include  the  entire  diaphysis,  one-half  of  the  mandible  or 
external  surface  of  the  maxilla  or  a  considerable  portion  of 
the  alveolar  process.  If  treatment  does  not  effect  resolu- 
tion, the  skin  may  become  reddened  and  adherent,  and  ul- 
cerate. Necrosed  bone  is  cast  off  and  an  adherent  cicatrix 
remains.  Exostoses  may  result  from  new  bone  deposit. 
When  such  nodes  develop  on  the  inner  tables  of  the  cranial 


48  THE   VENEREAL  DISEASES 

bones,  pressure  upon  the  brain,  cord,  nerves  and  vessels 
may  give  rise  to  paralysis,  convulsions,  neuralgia,  and 
edema.  In  rarefying  osteitis  the  bone  substance  is  invaded 
through  the  Haversian  canals  and  the  bone  trabeculse  are 
thinned  and  absorbed.  The  bony  substance  is  replaced  by 
new  cell  formation.  Formative  osteitis  may  supervene 
with  resulting  eburnation.  In  gummatoses,  osteoperiostitis 
and  osteomyelitis,  the  cellular  infiltration  takes  the  form 
of  a  gumma,  tending  to  become  caseous.  If  the  bone  is  near 
the  surface,  ulceration  occurs  through  the  skin,  resulting 
in  an  adherent  scar.  Spontaneous  fracture  of  a  long  bone 
may  result  from  absorption  of  its  bony  substance.  When 
the  medulla  is  involved  (osteomyelitis)  caries  or  necrosis 
and  perforation  externally  or  internally  result  (especially 
in  the  frontal  and  parietal  bones  of  the  skull).  In  bone 
manifestations  X-ray  examinations  reveal  areas  of  greater 
or  lesser  density  than  the  normal. 

Dactylitis  is  an  affection  of  the  fingers  and  toes.  The 
process  may  begin  in  the  soft  tissues,  but  more  commonly 
starts  as  a  periostitis  or  osteomyelitis.  The  course  is 
chronic,  the  integument  swollen  and  tense,  but  not  inflamed 
nor  painful.  Absorption  of  the  gummatous  deposit  may 
shorten  the  phalanx,  and  either  a  false  joint  result  or, 
rarely,  ankylosis. 

In  the  muscles,  as  a  secondary  symptom,  occur  rheuma- 
toid pains,  but  there  is  no  permanent  structural  change.  The 
muscles  are  subject  to  tertiary  changes  (gumma  and  gum- 
matous infiltration),  which  result  in  contraction  or  soften- 
ing and  ulceration.  Ninety-five  per  cent,  of  all  muscle  tu- 
mors are  of  syphilitic  origin. 

The  various  organs  of  the  body  are  subject  to  the  dis- 
ease. The  liver  is  more  commonly  affected  than  any  other 
of  the  internal  organs.  Syphilis  of  the  kidneys  is  not  un- 
common. The  eye  is  frequently  afi^ected  in  one  or  other 
of  its  structures.  The  heart  is  rarely  involved,  but  myo- 
carditis, endocarditis  and  pericarditis  do  occur.    The  arte- 


SYPHILIS  49 

ries  are  affected,  particularly  those  of  the  brain.  Syphilis 
predisposes  to  arterial  sclerosis. 

Late  lesions  of  the  nervous  system  are  the  most  serious 
manifestations  of  the  disease.  The  symptoms  may  be  pro- 
duced by  pressure  from  affection  of  the  bones,  diffuse  intil- 
tration  or  multiple  gumma  of  the  meninges,  thrombosis, 
rupture  or  aneurism  from  arteritis  or  by  gummata.  Cere- 
bral involvement  is  usually  manifested  by  headache,  vertigo, 
nausea,  vomiting,  epileptic  convulsions,  paralysis  or  hemi- 
plegia. Among  the  spinal  symptoms  are  pain,  hyperesthe- 
sia and  anesthesia,  sensory  and  vasomotor  disturbances, 
paralysis  and  atrophy.  The  parasyphilitic  diseases  (post- 
syphilitic degenerative  processes)  are  locomotor  ataxia 
(tabes)  and  paresis.  The  presence  of  syphilis  in  the  system 
predisposes  to  these  degenerations,  but  the  process  is  not 
pathologically  syphilitic. 

Inherited  Syphilis.— Inherited  syphilis  may  be  transmit- 
ted by  the  father  at  the  time  of  insemination,  by  the  mother 
at  the  time  of  conception,  or  later  from  the  mother  by  the 
placental  circulation  (post-conceptional).  There  may  be 
abortions,  miscarriages  between  the  fourth  and  seventh 
months,  or  later  healthy  children.  Five  years  after  the  ini- 
tial lesion  syphilis  ceases  (as  a  rule)  to  be  transmissible 
from  the  father,  but  a  syphilitic  mother  may  transmit  the 
disease  for  a  much  longer  time. 

A  syphilitic  child  is  usually  small,  undeveloped,  and  has 
an  aged  appearance.  The  skin  is  loose  and  wrinkled  and 
of  a  coffee-colored  tint.  The  nails  are  ill-developed.  The 
bullous  syphilide  (pemphigus)  is  one  of  the  earliest  and 
most  marked  symptoms.  Vesicles  containing  serous  fluid 
form,  the  contents  become  milky  or  yellowish  and  sometimes 
bloody,  then  burst;  greenish-yellow  scabs  form  with  ulcer- 
ation beneath.  On  the  mucous  membranes  we  find  excoria- 
tions, mucous  patches,  fissures,  and  ulcers.  Ulcers  of  the 
gums  may  induce  caries  or  necrosis  of  the  bones.  A  swell- 
ing and  redness  (the  sniffles)  of  the  mucous  membrane  of 


50 


THE   VENEREAL   DISEASES 


the  nose  are  early  and  marked  symptoms.    There  is  a  serous 
discharge  which  becomes  purulent,  sanious,  and  of  offensive 


Fig.  5. — Diffused  Syphilitic  Periostitis  of  Hereditary  Origin.  Photo- 
graphs of  a  boy  eight  years  old,  who  has  enlargement  of  both  tibia,  right 
radius  and  left  ulna.  The  case  was  confounded  with  rachitical  enlarge- 
ment of  these  bones.  Tuberculosis,  hypertrophic  osteitis  and  pyemic 
periostitis  were  all  considered,  and  it  was  only  after  the  case  had  been 
placed  under  specific  medication  that  the  diagnosis  was  made  absolute. 
The  interesting  feature  of  the  case  is  that  there  was  httle,  if  any,  pain, 
but  a  slight  tenderness,  and  the  child  continued  about  at  play  and  enjoyed 
the  usual  health  and  freedom  of  conduct.  lodid  of  potash  treatment  was 
pursued  and,  in  the  course  of  several  months,  the  hypertrophic  conditions 
disappeared  and  there  was  no  return  for  10  years,  when  other  bone  lesions 
developed  and  required  treatment. 

odor.     Crusts  form,  beneath  which  are  excoriations  and 
ulcers.    Breathing  becomes  difficult  and  noisy.    The  catarrh 


SYPHILIS  51 

may  extend  to  the  laTynx,  making  tlie  voice  hoarse,  husky 
and  stridulous.  Otitis  media  develojjs  painlessly,  giving  no 
symptoms  except  a  purulent  discharge.  Deafness  (labyrin- 
thine) develops  rapidly  and  is  complete.  Iritis  and  inter- 
stitial keratitis  are  frequent.  The  upper  permanent  central 
incisors  have  crescentic  notches  at  their  free  edges  (Hutch- 
inson's teeth).  The  enamel  is  deficient  in  the  middle  of  the 
notch  (the  bevel  being  at  the  expense  of  the  anterior  sur- 
face). As  the  teeth  wear  down  with  use,  the  characteristic 
appearance  does  not  persist  beyond  about  the  twenty-fifth 
year.  Other  irregularities  of  the  teeth  occur,  but  are  not 
so  constantly  found.  Osteochondritis  (exclusively  a  syphi- 
litic lesion)  consists  in  an  infiltration  of  the  diaphysis  of  a 
bone  at  its  junction  with  the  epiphysis,  producing  a  swell- 
ing at  this  point.  Degenerative  changes  may  occur  and 
ulceration  of  the  skin  result.  Separation  of  the  diajDhysis 
from  the  epiphysis  may  occur,  j^roducing  ' '  syphilitic  i^seudo- 
paralysis"  of  the  newborn.  This  process  begins  in  ufero. 
Periostitis  occurs  later,  and  the  changes  are  hypertrophic, 
13roducing  osteophytic  growths  (nodes  and  bosses).  The 
liver,  when  affected,  is  enlarged  and  hardened.  The  Spiro- 
chaeta  pallida  is  found  in  greatest  numbers  in  the  liver  of 
the  syphilitic  fetus  dead  of  the  disease. 

Prognosis.— The  prognosis  of  sypliilis  is  good  if  the 
diagnosis  is  made  early  and  efficient  treatment  instituted. 
Constitutional  disorders,  bad  hygiene,  dissipation,  alcohol- 
ism and  overwork  account  in  gTeat  measure  for  the  viru- 
lence of  the  disease.  The  use  of  tobacco  is  largely  responsi- 
ble for  the  recurrence  and  jDersistence  of  the  mouth  lesions. 
The  best  protection  that  can  be  offered  against  tertiary 
symptoms  is  early,  thorough  treatment.  Statistics  show 
that  syphilis  shortens  the  expectancy  of  life. 

Treatment.— General  hygienic  measures  and  outdoor 
exercise  are  important.  Mercury,  arsenic  and  the  iodids 
are  used  for  the  specific  effects.  Mercury  and  arsenic  heal 
the  lesions  and  prevent  relapses  by  killing  the  Spirochteta 


52 


THE  VENEREAL  DISEASES 


pallida.  The  iodids  are  an  adjuvant  and  of  special  service 
in  accomplisliing  tlie  resolution  of  tertiary  manifestations. 
Mercury  is  administered  by  mouth,  by  inunction,  hypo- 


FiG.  6. — Congenital  Diffused  Specific  Periostitis,  Suppurating  at  Many 
Points.  Within  three  months  there  were  twenty-four  points  broken  down 
and  discharging.  The  sinuses  shown  over  left  elbow  and  head  of  right 
radius  mark  recent  large  gummata. 

dermic  injection,  fumigation  and  intravenous  injection. 
Prof.  Ehrlich  of  Frankfort,  Germany,  has  lately  presented 
to  the  profession  the  arsenical  preparation  known  as  "606" 
(Dioxy-diamido-arseno-benzol,   patented   under    the    name 


SYPHILIS  53 

"Salvarsan"),  wMcli  is  administered  by  subcutaneous  and 
intramuscular  injection  and  by  intravenous  transfusion. 
The  results  from  its  use  are  far  superior  in  the  control  of 
symptoms  to  those  attained  by  mercurial  medication.  The 
permanency  of  its  effect  cannot  be  attested,  as  ^'606"  has 
been  in  general  use  only  a  few  months.  The  cure  of  syphilis 
in  the  absence  of  symptoms  should  be  judged  of  by  the  Was- 
sermann  (or  Noguchi)  blood  test. 


CHAPTER  VI 


WOUlSrDS   AND    HEMOEEHAGE 


Surgical  Emergencies : 

(A)  Wounds  and  their  treatment. 

(B)  Hemorrliage. 

(C)  Burns,  scalds,  frost  bites  and  freezing. 

(D)  Injuries  to  the  brain  and  skull. 

(E)  Foreign  bodies  in  the  eye,  ear,  nose  and  throat. 

(A)  WOUNDS 

A  wound  is  an  injury  of  the  skin,  or  the  parts  under- 
neath, as  a  result  of  a  blow  or  some  form  of  violence. 
Wounds  are  simple  when  they  remain  local,  have  a  tendency 
to  recover  instead  of  spreading  to  other  parts,  and  produce 
no  appreciable  constitutional  disturbance.  Wounds  are  in- 
fective when  they  have  been  inoculated  with  bacteria,  in 
which  event  the  tendency  is  to  spread  or  involve  other  parts 
and  become  general,  resulting  usually  in  systemic  disturb- 
ances. These  conditions  may  be  considered  varieties  of  in- 
flammation. The  latter  is  commonly  known  as  blood  poison- 
ing. 

Wounds  are  divided  into:  (a)  contused;  (b)  lacerated; 
(c)  incised;  (d)  punctured;  (e)  poisoned;  (f)  gunshot. 

(a)  Contusions.— Contusion  is  commonly  known  as  a 
bruise,  and  is  a  term  applied  to  injuries  of  the  soft  tissues, 
due  to  blows,  as  from  a  fist,  causing  a  "black  eye,"  or  from 
a  stone  or  a  whip.  There  is  generally  some  discoloration  of 
the  parts,  due  to  transfusion  of  red  blood  corpuscles  from 

54 


WOUNDS  55 

the  small  blood  vessels  into  the  surrounding  tissue,  and 
swelling  is  generally  found,  which  is  due  to  the  escape  of 
serum  and  corpuscles  from  the  small  blood  vessels.  The 
pain  is  caused  by  the  actual  injury  of  the  parts  and  the  pres- 
sure produced  by  the  escaped  corpuscles  and  serum.  Con- 
tusion may  be  quite  simple  where  a  slight  abrasion  is  pres- 
ent, or  it  may  involve  an  extensive  area,  as  may  be  seen  in 
railroad  accidents. 

Treatment  for  simple  contusions  is  rest,  simple  lotions, 
as  boric  acid  or  normal  salt  solution,  to  protect  the  parts 
from  the  air  and  prevent  infection.  For  extensive  contu- 
sions cold  applications  for  the  first  few  hours,  followed  by 
heat  after  the  acute  stage,  are  good  dressings.  Anodyne 
lotions,  as  laudanum,  are  also  beneficial,  since  they  not  only 
act  upon  the  capillary  blood  vessels  and  produce  local  anes- 
thesia and  thus  relieve  pain,  but  they  are  also,  as  a  rule, 
antisei3tic  and  cause  the  wound  to  remain  a  simple  one. 

(b)  Lacerations.— Lacerations  are  tears  of  the  soft  parts 
made  by  some  blunt  object,  such  as  those  resulting  from 
railroad  or  machinery  accidents,  those  produced  in  fights 
or  made  by  a  policeman's  mace. 

Treatment. — Here  the  general  rule  as  to  the  manage- 
ment of  all  wounds  should  be  observed,  viz.,  use  clean  cloths, 
surgeon's  cotton  or  gauze  which  has  been  in  boiling  water, 
and  keep  all  filthy  material  from  the  wound.  Slight  oozing 
may  be  controlled  by  hot  applications.  Soap  liniment,  dilute 
alcohol,  whisky,  and  laudanum  are  the  best  lotions  both  to 
control  hemorrhage  and  to  prevent  inoculation.  Adjust  the 
lacerated  parts  if  possible  and  hold  them  in  position  by  the 
use  of  compress  and  bandage,  taking  care  not  to  apply  the 
bandage  too  tightly. 

(c)  Incised  Wounds.— Incised  wounds  are  clean-cut 
wounds,  made  by  some  sharp  instrument,  such  as  a  knife, 
and  their  length  is  greater  than  their  depth. 

Treatment. — "When  small  and  not  too  deep,  or  when  not 
attended  by  alarming  hemorrhage,  adjustment  of  the  edges 


56  WOUNDS   AND   HEMORRHAGE 

by  the  use  of  adhesive  plaster  will  be  sufficient.  When  exten- 
sive, the  best  that  can  be  expected  as  a  temporary  aid  is  to 
make  an  effort  to  adjust  the  parts  and  control  the  hem- 
orrhage by  direct  pressure.     Suture  the  skin. 

(d)  Punctured  Wounds.— A  punctured  wound  is  one 
where  the  depth  is  greater  than  the  surface  length.  It  may 
be  incised  when  made  by  a  cutting  instrument,  and  lacerated 
when  a  hook  or  other  similar  instrument  pierces  the  soft 
l^arts.  Punctured  wounds  are  made  by  pins,  needles,  wire 
nails,  thorns,  splinters,  knives,  hooks,  glass,  etc.,  and  the 
varieties  may  be  profitably  considered  separately. 

Pins  and  needles  usually  produce  harmless  wounds,  ex- 
cept when  they  puncture  an  important  cavity  or  blood  ves- 
sel. When  inoculation  occurs,  serious  and  possibly  fatal 
inflammation  may  result.  When  a  blood  vessel  is  punctured, 
internal  hemorrhage  may  occur,  producing  a  condition 
known  as  false  aneurism,  which  will  recjuire  operation  (see 
Hemorrhage).  AVhen  a  needle  is  driven  entirely  into,  or 
broken  off  below,  the  soft  parts  of  the  skin,  it  is  difficult 
to  remove.  If  the  course  of  the  needle  is  such  as  to  make 
it  possible,  the  incision  should  be  made  half  an  inch  or  so 
from  the  point  of  puncture  and  the  knife  should  strike  the 
side  rather  than  the  point  of  the  needle.  To  cut  directly 
through  the  point  of  puncture  would,  theoretically,  be  the 
best  method,  but  in  practice  it  furnishes  many  fruitless 
efforts  to  locate  the  object  of  search.  Too  much  damage 
should  not  be  done  to  soft  parts  in  a  search  for  a  needle, 
since  it  is  inorganic  matter  and  its  presence  causes  little  ill 
result. 

Thorn  and  splinter  wounds  furnish  a  different  condi- 
tion, since  wood  is  organic  matter  and  never  becomes  en- 
capsulated, but  acts  as  an  irritant.  It  should,  therefore,  be 
removed  j^romptly.  After  removal  little  trouble  results  and 
healing  takes  place  promptly.  Large  splinters  produce  ex- 
tensive lacerations,  which,  after  removal  of  the  splinter, 
should  be  treated  as  other  lacerated  wounds.    Splinters  un- 


WOUNDS  57 

der  the  nails  are  troublesome  and  may  require  the  scraping 
or  splitting  of  the  nail  before  they  can  be  removed.  A  most 
dangerous  variety  of  punctured  splinter  wound  is  that  in 
which  the  splinter  enters  an  important  cavity  of  the  body, 
such  as  the  eye,  abdomen  or  pleura. 

In  wounds  due  to  glass,  the  glass  should  be  removed  if 
this  can  be  readily  done,  but  it  causes  no  injury  to  the  parts, 
and  should  be  allowed  to  remain  until  the  arrival  of  the  sur- 
geon when  there  is  any  difficulty  attending  the  removal. 

When  a  fish  hook  has  entered  the  soft  parts,  the  point 
should  be  pushed  out  through  the  skin.  The  eye  will  pre- 
vent its  being  carried  entirely  through.  The  hook  may  be 
broken  either  by  a  couple  of  pliers  or  wire  cutters,  when 
the  fragments  are  withdrawn. 

Nail  wounds,  especially  the  old  cut  nails,  produce  most 
troublesome  wounds.  Infection  is  quite  common,  and  ery- 
sipelas or  other  infective  inflammation  may  result;  hence, 
the  importance  of  first  treatment.  After  removal  of  the 
nail,  the  sinus  should  be  injected  with  tincture  of  iodin, 
alcohol  fifty  per  cent.,  or  other  antiseptic  solution.  The 
wound  should  be  kept  open  rather  than  closed,  to  afford 
drainage. 

For  the  treatment  of  all  of  these  varieties  of  incised, 
punctured  and  lacerated  wounds  cleanliness  should  be  ob- 
served, hemorrhage  controlled  by  direct  pressure,  hot  or 
anodyne  lotions  should  be  used,  and  gauze  or  cotton  applied 
next  to  the  skin,  over  which  a  bandage  should  be  placed. 

(e)  Poisoned  Wounds.— Poisoned  wounds  are  those 
which  are  inoculated  at  the  time  they  are  produced,  and 
must  be  considered  as  a  variety  of  infective  inflammation 
from  the  start.  In  certain  wounds  there  may  be  a  question 
as  to  whether  infection  has  taken  place.  Bites  of  dogs,  cats 
and  rats  may  result  in  infection,  but,  as  a  rule,  they  do  not. 

Stings  from  bees  and  spiders  produce  swelling  and  some 
local  disturbance,  requiring  local  aijplications,  but  death 
seldom  follows.     Stings  from  tarantulas,  scorpions,  centi- 


58  ^^OUXDS   AND   HEMORRHAGE 

pedes,  and  bites  of  copperheads  or  rattlesnakes  are  poison- 
ous and  absorption  takes  place  in  a  few  minutes.  Local 
treatment  consists  of  cauterization  by  acid,  hartshorn,  pure 
alcohol  or  with  a  hot  needle.  When  an  extremity  is  wounded 
in  this  way  it  should  be  encircled  above  the  wound,  with  a 
rubber  band,  or  very  tight  bandage. 

Dog  bites  are  seldom  poisonous.  Of  those  dogs  which 
ajDpear  mad  on  the  street,  few  are  really  so.  A  dog  which 
api^ears  mad  and  has  bitten  some  one  should  be  caught  and 
23enned  up  for  three  weeks  to  definitely  determine  its  condi- 
tion.    (See  Hydrophobia.) 

(f)  Gunshot  Wounds.— Gunshot  wounds  almost  always 
involve  deep  structures,  and  little  can  be  done  or  should  be 
attempted  toward  treatment  until  the  arrival  of  the  surgeon. 
Eest  and  antiseptics,  and,  in  case  of  hemorrhage,  pressure 
to  control  the  same,  are  about  the  only  means  of  treatment 
to  be  emi^loyed  by  the  dentist. 

(B)  HEMORRHAGE 

Hemorrhage  is  the  escape  of  blood  from  a  blood  vessel. 
It  is  internal  or  concealed,  when  it  cannot  be  seen,  and  ex- 
ternal when  the  flow  is  from  an  external  wound.  Bright 
red  blood  comes  from  an  artery  and  usually  escapes  with  an 
interrui3ted  spurt.  Dark  red  blood  which  escaj)es  with  a 
continuous  flow  is  from  a  vein.  The  reason  why  one  so 
easily  bleeds  to  death  from  an  artery  and  not  from  a  vein 
is  that  there  is  nothing  to  interrupt  the  flow  from  an  artery, 
as  they  have  no  valves,  as  do  the  veins,  where  no  backward 
flow  of  blood  can  occur. 

Control  of  External  Hemorrhage.— The  first  principle  in 
the  control  of  hemorrhage  from  small  cuts  or  lacerations, 
especially  those  about  the  head  and  face,  is  to  make  direct 
pressure  upon  or  into  the  wound  with  a  clean  piece  of  gauze 
or  cotton.  AVhen  the  vessel  from  which  the  blood  is  escap- 
ing is  not  too  large,  such  pressure,  if  kept  up  for  ten  or  fif- 


HE]\rOREHAGE  59 

teen  minutes,  will  control  it.  "\Mien  a  large  Wood  vessel  is 
severed  with  a  knife,  or  where  a  limb  is  torn  from  the  body 
and  the  patnlons  ends  of  the  vessels  are  bleeding  freely, 
pressnre  must  be  made  above  the  point  of  hemorrhage.  This 
may  be  done  by  making  direct  pressnre  ni3on  the  artery 
with  the  thumb,  or  when  the  hemorrhage  is  from  an  extrem- 
ity, it  may  be  girdled  with  a  handkerchief  or  any  kind  of 
fabric  tight  enongh  to  stop  the  flow.  Such  a  tonrniqnet 
makes  jjressnre  best  if  a  stone  or  other  firm  object  is  nsed, 
being  placed  in  the  folds  of  the  handkerchief  and  laid  di- 
rectly over  the  artery.  A  stick  may  be  tied  in  the  second 
knot  on  the  opposite  side  of  the  leg  from  the  vessel.  By 
turning  this,  sufficient  pressure  may  be  made  to  control  the 
hemorrhage.  In  making  application  of  any  variety  of  tour- 
niquet, care  must  be  taken  to  apply  it  tightly  enough  to  con- 
trol the  flow,  but  if  applied  for  many  hours  gangrene  may 
result. 

Internal  Hemorrhage. — Hemorrhage  may  occur  from 
the  cavities  of  the  body,  as  the  mouth,  nose,  stomach,  lungs, 
intestines,  or  from  the  uterus. 

Nasal  hemorrhage  is  the  most  frequent  variety,  and  is 
usually  from  the  mucous  membrane  of  the  anterior  superior 
portion  of  the  nasal  cavity.  The  most  alarming  hemor- 
rhages occur  from  the  roof  of  the  cavity  well  back.  Ordi- 
nary hemorrhage  from  the  anterior  surface  may  be  con- 
trolled by  making  pressure  against  the  side  of  the  nose  with 
the  thumb,  or  by  the  application  of  cold  cloths  to  the  back 
of  the  neck,  with  the  body  in  the  upright  i30sition.  Astrin- 
gent douches  may  be  injected  up  the  nose  with  benefit,  but 
care  must  be  taken  not  to  damage  the  nasal  mucous  mem- 
brane with  the  douche  tip.  Packing  the  cavity  with  gauze 
or  plugging  the  posterior  and  anterior  nares  must  be  left 
to  the  physician.  Nasal  hemorrhage  may  be  a  symptom  of 
typhoid  fever. 

Hemorrhage  from  the  mouth  after  the  extraction  of  a 
tooth  is  not  an  infrequent  complication.     It  may  be  con- 


60  "WOUNDS   AND   HEMORRHAGE 

trolled,  usually,  by  first  cleansing  tlie  tootli  socket,  swabbing 
witli  Monsel's  solution,  and  afterward  packing  it  with  gauze 
or  cotton. 

Hemorrbage  in  the  stomach  is  only  made  manifest  when 
the  blood  is  vomited,  and  then  it  may  be  mixed  with  the 
food  and  be  difficult  to  recognize.  It  is  controlled  by  salt 
or  ice  taken  into  the  stomach  and  cold  applications  over  the 
pit  of  the  stomach. 

Hemorrhage  from  the  bowels  in  individuals  in  apparent 
health,  or  from  hemorrhoids,  is,  as  a  rule,  not  dangerous. 
It  may  be  controlled  by  recumbency  and  applications  or  in- 
jections of  iced  vinegar. 

Hemorrhage  from  the  lungs  of  those  suffering  with  con- 
sumption is  most  alarming,  but  from  individuals  in  appar- 
ent health  is  of  little  consequence.  Treatment  consists  in 
quiet,  administration  of  ice  pills,  salt,  or  a  half-teaspoonful 
of  F.  E.  ergot,  repeated  in  a  half  hour  or  less  time,  if  neces- 
sary. 

Uterine  hemorrhage  is  best  controlled  by  recumbency, 
with  the  head  lower  than  the  feet,  the  administration  of  F. 
E.  ergot,  and  hot  vaginal  injections. 

A  general  rule  which  may  be  of  service  is :  If  the  flow 
is  above  the  heart  allow  the  patient  to  sit  up,  and  if  below 
have  him  lie  down.  The  position  diminishes  the  pressure 
by  encouraging  gravitation. 

(C)  BURNS  AND  SCALDS 

Burns  from  a  flame  or  acid  and  scalds  are  dangerous  if 
two-fifths  of  the  surface  of  the  body  is  involved ;  and  when 
more  than  this  amount  of  skin  is  destroyed  the  result  is 
usually  fatal.  The  destruction  of  a  smaller  amount  of  sur- 
face than  this  may  terminate  fatally  when  the  deep  struc- 
tures are  involved  or  when  steam  has  been  inhaled,  "^^^len 
the  clothing  is  aflame,  the  imfortunate  should  be  forced  to 
lie  down,  and  a  blanket,  coat,  carpet,  or  some  fabric  large 


BURNS  AND  SCALDS  61 

enough  to  envelop  the  body  thro\\Ti  around  him.  Everj'thing 
must  be  done  to  keep  the  flames  away  from  the  face,  so  that 
the  hot  air  may  not  enter  the  lungs.  The  pain  and  shock  are 
proportionate  to  the  amount  of  surface  destroyed  and  the 
depth  of  the  burn,  and  these  conditions  increase  as  treat- 
ment is  delayed. 

Treatment.— After  the  flame  is  extinguished  the  burned 
clothing  should  be  carefully  removed  and  the  burned  sur- 
face exposed,  so  that  dressing  may  be  applied  immediately 
to  protect  the  raw  surfaces  from  the  air  and  thus  prevent 
pain  and  subsequent  shock.  Blisters  should  be  punctured 
near  the  margin,  so  that  the  liquid  may  escape  and  allow 
the  epidermis  to  collapse.  The  dead  skin  should  be  removed, 
since  pus  may  gather  underneath  and  cause  fever.  The  best 
immediate  dressing  is  carron  oil  (linseed  oil  and  lime  water 
in  equal  parts)  applied  to  the  exposed  surface  with  saturat- 
ing gauze  or  soft  muslin ;  over  this  cotton  batting  should  be 
wrapped,  and  this  dressing  held  in  jDOsition  with  a  bandage. 
Oxid  of  zinc  ointment  (1  dram  of  z.  o.  to  1  oz.  of  vaseline) 
spread  on  lintine  makes  the  best  permanent  dressing  for 
burns.  This  should  be  changed  daily.  The  first  idea  of 
treatment  is  to  make  a  substitute  for  the  destroyed  epi- 
dermis at  the  earliest  possible  moment.  Solutions  of  bak- 
ing soda,  sweet  oil,  castor  oil,  vaseline,  lanolin,  etc.,  make 
good  dressings  and  should  be  applied  as  directed  above. 
Gauze  or  flannel  immersed  in  hot  water  is  an  excellent  dress- 
ing. Stimulants  and  opiates  in  proper  doses  should  be  ad- 
ministered as  necessary. 

Acids,  such  as  vitriol,  produce  painful  burns.  Burns 
of  this  sort  should  immediately  be  bathed  in  soda  solution 
or  soap  suds,  and,  after  cleansing  in  hot  water,  should  be 
dressed  as  other  burns.  Alkalies  produce  an  injury  similar 
to  the  foregoing  and  require  similar  treatment,  except  that 
vinegar  or  some  other  mild  acid  solution  should  be  applied 
immediately  after  the  accident. 

Burns  from  guniDOwder  are  treated  by  first  cleansing  the 


62  "WOUNDS   AND   HEMORKHAGE 

parts  with  hot  water,  then  briskly  rubbing  the  skin  with  a 
towel  or  sponge,  which  dislodges  the  particles  of  powder 
not  deeply  imbedded.  The  removal  of  the  deep  particles 
should  be  done  by  a  physician,  but  if  one  cannot  readily  be 
found,  another  may  remove  them  with  a  sharp  needle,  which 
should  be  sterilized  by  passing  it  through  a  flame  or  immers- 
ing it  in  hot  water  or  alcohol. 

Frost  bites  and  freezing  are  of  frequent  occurrence  in 
country  districts,  and  railroad  and  street  car  employees 
often  suffer  from  them.  Treatment  consists  in  rubbing  the 
parts.  The  practice  of  using  ice,  snow  or  ice  water  is  all 
right,  but  the  friction  does  the  good  whether  it  is  done  with 
ice  or  with  the  hand.  Temperature  should  be  elevated  grad- 
ually. When  an  individual  is  frozen  to  stupor,  or  to  uncon- 
sciousness, friction  and  gradual  elevation  of  the  tempera- 
ture of  the  room,  with  stimulants  and  artificial  respiration, 
are  means  most  likely  to  restore  life.  A  bath,  with  the  wa- 
ter slightly  warmed  and  the  temperature  gradually  elevated, 
should  be  resorted  to  if  necessary,  after  which  the  patient 
should  be  wrapped  in  warm  blankets. 

(D)  INJURIES  TO  BRAIN  AND  SKULL 

Fractures  of  the  skull  or  injuries  to  the  brain,  resulting 
in  concussion  or  compression,  have  for  sj^njotoms  incoherent 
talking,  stupor  (from  which  the  patient  may  be  aroused) 
or  unconsciousness.  In  fractures  of  the  skull  with  compres- 
sion there  will  be  profound  stupor,  irregular  breathing, 
irregularly  contracted  pupils  and  possibly  paralysis  of  one 
or  more  extremities. 

In  concussion,  or  where  there  is  a  simple  "shaking-up" 
of  the  brain,  the  impression  is  not  so  great,  it  usually  being 
possible  to  arouse  the  patient  sufficiently  to  respond  to  ques- 
tions. The  history  of  an  injury,  such  as  a  fall  or  a  blow, 
will  assist  in  making  a  diagnosis.  Brinton  gives  the  follow- 
ing diagnostic  points: 


FOREIGN    BODIES 


63 


Concussion. 

1.  Incomplete  insensibility. 

2.  Partial  muscnlar  action. 

3.  Special   senses  act  par- 

tially. 

4.  Patient  can  answer  ques- 

tions if  aroused. 

5.  Pulse  quick,  feeble,  and 

often  intermittent. 

6.  Skin   cold;   temperature 

falls    to    94   or   95   de- 
grees. 

7.  Respiration 

quiet. 

8.  Nausea  and  vomiting. 

9.  Pupils  regular. 


Compression. 
Complete  insensibility. 
Paralysis, 
Special    senses    do    not 

act. 
Patient    cannot    answer 

questions  if  aroused. 
Pulse  slow  and  laboring. 


6. 


Skin  hot  and  perspirmg ; 
temperature  102  to  104 
degrees, 
feeble;       7.  Respiration    is    labored, 
stertorous. 

8.  No  nausea  or  vomiting. 

9.  Pupils  irregularly  dilat- 
ed. 

10.  Eyelids     irregularly 
closed. 

11.  Retention   of  urine;   in- 
voluntary escape  of  fe- 

ces. 
Treatment,  until  tlie  surgeon  arrives,  consists  in  enforc- 
ing absolute  quiet  in  recumbency.     No  whisky  should  be 
administered.    Cold  may  be  applied  to  the  head  and  water 
given  the  patient  to  drink  if  he  desires  and  can  take  it. 


10.  Eyelids  somewhat  open. 


11 


Urine  voided: 
tained. 


feces  re- 


(E)  FOREIGN  BODIES 

In  the  Eye.— Foreign  bodies  in  the  eye  may  be  removed 
with  a  spud  or  sterile  gauze.  The  lid  may  be  everted  by 
having  the  patient  look  down,  while  the  lid  is  grasped  be- 
tween the  thumb  and  index  finger  of  one  hand,  and  the  cen- 
tral part  is  pushed  down  with  a  sterile  probe.  The  lid  is 
then  turned  up.  This  exposes  the  under  surface  of  the  lid, 
where  the  foreign  body  is  usually  found.     When  the  for- 


64  WOUNDS   AND   HEMORRHAGE 

eign  body  is  on  the  cornea  (or  ball),  if  it  cannot  readily  be 
removed  with  some  blunt  instrument,  an  oculist's  services 
should  be  sought.  If  there  is  much  pain,  cocain  (two 
per  cent.)  should  be  dropped  into  the  eye  and  impalpable 
boric  acid  should  be  dusted  in  afterward,  if  there  is  much 
congestion. 

In  the  Nose. — Foreign  bodies  in  the  nose  are  usually 
pushed  farther  in  unless  the  effort  for  removal  is  made  with 
a  flat,  blunt  instrument,  such  as  a  bodkin  needle,  entered 
above  the  object.  The  hand  is  elevated,  dragging  the  object 
downward  and  forward  and  usually  out. 

In  the  Ear. — Foreign  bodies  in  the  ear  do  little  damage; 
indeed,  they  do  less  damage  if  left  alone  than  is  done  by  an 
unskilful  effort  at  removal,  as  it  is  not  an  unusual  accident 
to  injure  the  ear-drum  by  pushing  an  object  in  against  it. 
A  physician  should  be  asked  to  remove  foreign  bodies  from 
the  ear. 

In  the  Throat. — Foreign  bodies  in  the  throat  are,  as  a 
rule,  due  to  accidents  of  childhood,  and  must  be  removed  at 
once.  This  can  be  done  by  entering  the  index  finger  in  the 
mouth,  to  one  side,  and,  with  the  tip,  hooking  the  object  out. 
Care  must  be  taken,  as  an  aimless  effort  will  push  the  object 
farther  down  and  do  more  harm  than  good. 

In  the  Larynx.— When  objects  pass  into  the  larynx,  a 
most  serious  condition  is  presented.  Grains  of  corn,  beans, 
buttons,  etc.,  if  they  enter  the  windpipe,  are  drawn  into  the 
lungs  by  the  first  breath  and  may  occlude  one  entire  lung, 
resulting  in  almost  instant  death.  Suddenly  turning  the 
patient  head-downward  and  striking  the  back  may  dislodge 
the  body  and  throw  it  off.  This  condition  will  be  recognized 
by  the  extreme  difficulty  in  breathing.  When  bodies  are 
retained  in  the  windpipe  any  length  of  time  they  produce  a 
dropsy  of  the  mucous  membrane,  which  greatly  complicates 
matters,  hence  the  desirability  of  immediate  removal.  The 
doctor  should  be  summoned  at  once,  and  he  must  be  in- 
formed as  to  the  condition  and  be  prepared  to  perform 


FOREIGN  BODIES  65 

tracheotomy  (or  opening  the  windpipe  through  the  throat) 
in  order  that  the  object  may  be  removed.  Foreign  bodies 
are  now  located  and  removed  with  the  laryngoscope. 

In  the  Stomach.— When  objects  are  swallowed,  they  are 
not  necessarily  dangerous.  Tubes  three  inches  long,  used 
for  intubating  the  larynx  in  cases  of  membranous  croup, 
are  swallowed  and  pass  from  the  bowels  in  three  or  four 
days  and  do  no  harm ;  and  a  case  is  reported  where  a  five- 
year-old  negro  girl  swallowed  a  barb-wire  staple,  and  it 
passed  in  four  days  without  causing  a  particle  of  trouble. 
The  patient  should  be  fed  mashed  potatoes  or  solid  mate- 
rials, which  surround  the  object  and  help  to  carry  it  along 
the  alimentary  canal.  Round  bodies,  such  as  bones,  when 
not  too  large,  and  coins,  may  be  pushed  into  the  stomach, 
where  they  do  no  harm  and  pass  off  in  a  few  days.  Sharp 
objects,  as  fish-hooks,  hatpins,  and  sharp-pointed  instru- 
ments, must  be  removed  at  all  hazard.  Little  attempt  at 
removal  must  be  made  by  anyone  but  a  physician,  who 
should  be  summoned  with  all  haste.  Instances  are  reported 
where  false  teeth,  table  fork,  hatpins  and  scarf-pins  have 
been  removed  from  the  stomach  through  a  gastroscope. 
When  this  fails,  an  abdominal  section  is  required. 


CHAPTER  VII 


BAXDAGIXG 


Bandages  are  iisiially  made  from  muslin  or  cheesecloth, 
Ijnt  they  may  be  of  flannel  or  rubber  webbing. 

Uses  of  Bandag'es.— Bandages  are  used  as  follows:  a.  To 
hold  dressings  in  position;  b.  to  secure  splints  and  appli- 
ances in  position;  c.  to  support  injured  parts;  d.  to  control 
bleeding  by  making  pressure. 

Varieties  of  Bandag'es.— There  are  sis  varieties  of  band- 
ages: a.  Boiler;  b.  triangular;  c.  four-tailed;  d.  many- 
tailed  ;  e.  T  and  double-T ;  f .  speciaL 

The  ordinary  roller  bandage  is  of  most  universal  service 
and  is  made  of  cheap  muslin,  cheesecloth,  flannel,  old  sheets 
or  bolster-cases.  In  applying  the  bandage  the  roll  must  be 
taken  in  the  right  hand,  the  back  of  the  bandage  held  to 
the  skin  with  the  left  thumb  resting  on  the  end.  The  follow- 
ing rules  may  be  observed  for  the  extremities : 

Begin  bandaging  at  the  toes  or  at  the  fingers  and  go 
toward  the  body.  Xever  bandage  an  extremity  from  the 
body.  Circular  turns  should  be  made  and  the  turns  re- 
versed where  the  extremity  is  conical,  so  that  the  edge  will 
not  cut  into  the  skin,  but  instead  the  pressure  will  be  uni- 
form. This  is  known  as  a  spiral  reversed  bandage.  Fig- 
ure-of-eight turns  should  be  made  over  the  joints  at  the 
knee  and  elbow. 

For  the  hip  and  shoulder  a  spica  serves  the  best.  For 
the  shoulder,  this  bandage  is  applied  by  making  two  or 
three  turns  around  the  arm  near  the  shoulder,  after  which 
the  bandage  is  carried  over  the  point  of  the  shoulder,  down 

66 


VARIETIES    OF    BANDAGES 


67 


across  the  chest  in  front,  under  the  opposite  arm  and  across 
the  back  to  the  point  of  the  injured  shoulder,  and  from 
there  it  is  carried  around  the  arm  to  the  point,  as  in  start- 


FiG.  7. — Roller  Bandages.  A.  Four-tailed  bandage  for  fracture  of  the 
lower  jaw  and  head.  B.  Reverse  spiral  for  the  shoulder.  C.  Figure-of- 
eight  for  the  elbow.  D.  Figure-of-eight  for  the  thumb.  Begin  at  the  wrist. 
E.  Roller  bandage  for  fracture  of  the  clavicle  and  injury  of  shoulder.  F. 
Ascending  spica  for  shoulder  and  arm.  Begin  near  the  elbow.  G.  Reverse 
spiral  for  the  forearm.  H.  Descending  spica  for  the  groin  and  hips.  Begin 
at  the  thigh.  I.  Gauntlet  for  the  fingers  and  thumb.  Begin  at  the  wrist, 
wrap  from  finger-tips  toward  hand  and  return  to  wrist  from  every  finger. 
J.  Spica  for  the  knee.  K.  Reverse  for  the  knee.  L.  Roller  for  big  toe. 
Begin  at  the  foot.     M.  Divergent  spica  for  the  heel. 


68 


BANDAGING 


ing.  This  is  repeated,  each  time  lapping  the  layers  about 
half  the  width  of  the  bandage  until  the  shoulder  is  covered. 
(Fig.  7.)  For  the  hip,  the  bandage  is  applied  in  the  same 
way,  except  that  it  goes  around  the  pelvis. 


Fig.  8— Triangular  Bandages.  A.  Triangular  bandage  for  the  head.  Free 
'  angle  is  turned  up  even  at  back  of  head  and  pinned.  B.  Triangular  bandage 
for  the  chest.  The  three  ends  are  tied  together  at  the  back.  It  is  reversed 
for  the  back!  C.  Triangle  for  the  shoulder.  The  upper  free  angle  may  be 
turned  down  or  the  knot  may  be  made  at  the  shoulder.  D.  Triangle  applied 
to  the  fist.  It  is  used  in  the  same  way  for  the  foot,  or  for  stumps  after  ampu- 
tation. E.  T"iangle  for  the  elbow.  F.  As  apphed  for  the  arm  or  elbow  and 
for  holding  splints  in  position.  G.  Triangle  for  the  hips.  H.  Circular 
bandage  about  the  pelvis  to  hold  triangle  of  hip  in  position.  I.  Triangle  for 
hand  and  wrist.  J.  and  K.  Triangles  as  apphed  to  the  knee.  L.  Triangle 
for  the  entire  foot.     M.  Triangle  for  the  heel. 


VAEIETIES    OF    BANDAGES  69 

The  triangle  is  a  most  convenient  bandage  and  can  be 
made  more  readily  than  the  roller  bandage,  since  smaller 
portions  of  muslin  are  necessary  and  an  ordinary  handker- 
chief serves  well.  The  triangle  is  best  for  the  head, 
neck,  shoulder,  hip  or  other  joints,  but  where  even  pres- 
sure is  desired  the  roller  is  best.  A  four-tailed  bandage  is 
used  for  the  chin  most  frequently.  Many-tailed  bandages 
are  used  for  the  abdomen  or  thorax,  and  are  used  by  apply- 
ing the  belly  of  the  bandage  in  front,  crossing  the  tails  in 
the  back,  and  bringing  them  forward,  where  they  are  tied 
or  pinned.     (Fig.  8.) 

Special  bandages  are  made  to  accomplish  special  pur- 
poses, such  as  to  make  traction  upon  an  extremity  in  frac- 
ture or  hip-joint  disease. 

Plaster-of-paris,  starch,  silicate  of  soda,  and  other  ma- 
terials are  incorporated  in  bandages  when  firmness  and 
permanency  are  required. 


CHAPTER  VIII 

SHOCK    AND    MEDICAL   EMERGENCIES 

SHOCK 

Shock,  commonly  known  as  collapse,  is  a  traumatic  tor- 
por of  the  system  following  injuries  and  surgical  opera- 
tions. In  this  condition  the  mechanism  of  the  vital  organs 
is  disconcerted. 

According  to  Kinneman :  ' '  Shock  must  not  be  consid- 
ered as  due  to  the  lowering  or  exhaustion  of  one  bodily 
function,  but  as  a  comj^osite  condition  embracing  an  inter- 
ference with  the  normal  height  of  the  blood-pressure  (low- 
ering), an  interference  (lowering)  with  the  respiratory  act, 
and  a  marked  fall  in  the  body  temperature.  Of  these,  as 
shock  increases  in  severity,  the  most  uniform  and  progres- 
sive factor  is  the  fall  in  temperature.  That  there  is  a  rela- 
tionship existing  between  the  fall  in  body  temperature  and 
shock  is  evident  by  considering:  (1)  That  in  one  series  the 
fall  in  temperature  was  the  sole  cause  of  the  shock;  (2) 
that  where,  by  continuous  bath,  the  temperature  fell  but 
one  degree  Centigrade  (average),  the  respirations  were 
increased  instead  of  diminished,  and  the  fall  in  blood-pres- 
sure was  greatly  lessened;  (3)  that  by  raising  the  body 
temperature  previously  lowered  in  shock,  the  respiratory 
rate  was  increased  and  the  blood-pressure  raised.  This 
relationship  may  be  thus  expressed:  (a)  A  sufficient  fall 
in  the  body  temperature  can  cause  a  decrease  in  the  respira- 
tory rate  and  a  marked  fall  in  the  blood-pressure,  which, 

70 


SHOCK  71 

together  with  the  former,  we  designate  as  shock;  (b)  con- 
versely, a  limiting  of  the  fall  limits  the  fall  in  pressure  and 
prevents  a  fall  in  the  respiratory  rate.  Therefore,  shock 
is  limited  or  prevented,  (c)  Antagonistically,  a  rise  of 
the  temperature  causes  a  rise  in  the  blood-pressure  and  the 
respiratory  rate  (reduced  in  shock),  with  the  result  of  a 
gradual  amelioration  of  all  the  symptoms.  Thus,  of  the 
three  factors  concerned,  the  temperature  commands  first 
place  by  its  power  of  production,  by  its  power  of  limitation, 
and  by  its  power  of  amelioration  of  the  comj^osite  condi- 
tion— shock. ' ' 

Symptoms.— The  symptoms  are  muscular  relaxation, 
with  a  white  skin,  and  usually  a  cold  and  clammy  sweat. 
The  features  are  pinched,  face  shrunken,  eyes  deep,  weird 
and  uncanny.  The  temperature  is  subnormal,  respiration 
and  pulse  slow.  There  is  reflex  vasomotor  and  pneumo- 
gastric  paresis.  Syncope  or  fainting  is  usual,  and  the  pa- 
tient lies  motionless  and  apparently  lifeless. 

Diagnosis.— Diagnosis  must  be  made  from  alcoholic  in- 
toxication, apoplexy,  brain  injury  and  from  drug  poisoning. 

Treatment. — The  general  management  of  cases  suffering 
from  shock  may  be  summarized  as  follows: 

(1)  Quiet,  rest  in  the  horizontal  position  and  artificial 
moist  heat  have  long  been  recognized  as  valuable  means  of 
restoring  the  lost  tone  to  the  vasomotor  system. 

(2)  The  head  should  be  lowered  enough  to  make  grav- 
ity aid  in  furnishing  sufficient  blood  to  nourish  and  excite 
to  proper  function  the  important  reflex  centers  of  respira- 
tion and  the  heart's  action  in  the  medulla,  as  well  as  the 
visceral  ganglia  in  the  lungs  and  heart  themselves. 

(3)  Experiments  have  conclusively  shown  that,  while 
shock  first  affects  the  vasomotor  system,  respiration  is 
early  impaired  .or  stopped,  sometime  before  the  heart's 
action  is  seriously  deranged  or  stopped,  and,  therefore,  arti- 
ficial respiration  may  be  the  means  of  continuing  life  by 
furnishing  oxygenated  blood  for  the  vital  centers  in  the 


72  SHOCK   AND   MEDICAL    EMERGENCIES 

medulla.     The  inhalation  of  oxygen  is  likewise  indicated 
for  the  same  purpose. 

(4)  The  interstitial  and  intravenous  injection  of  warm 
salt  solution  is  perhaps  our  most  efficient,  certain,  powerful 
and  lasting  remedy,  particularly  w^hen  there  has  been  hem- 
orrhage. "When  the  case  is  not  especially  urgent,  the  same 
solution  may  be  efficient  when  introduced  into  the  stomach 
or  rectum,  and  when  convenient  the  peritoneal  cavity  may 
be  used  for  the  same  purpose. 

(5)  The  therapeutic  remedies  are  those  which  will  re- 
store the  tone  of  the  vasomotor  system  and  support  respir- 
ation and  the  heart's  action.  Of  the  many  drugs  which 
have  been  recommended  and  used,  strychnia  probably 
rightfully  claims  the  most  friends,  used  in  the  way  the  oper- 
ator deems  best  to  reach  the  circulation  and,  so,  the  nerve- 
centers.  Next  come  digitalis,  strojihanthus,  nitroglycerin, 
and  ergot  in  approjoriate  doses. 

UNCONSCIOUS  CONDITIONS 

Coma. — Coma,  or  loss  of  consciousness,  is  a  state  of 
more  or  less  profound  insensibility  allied  to  sleep,  but  dif- 
fering from  natural  sleep  in  its  character  as  well  as  in  the 
circumstances  under  which  it  occurs.  The  long-continued 
action  of  cold,  and  the  narcotic  influence  of  alcohol,  opium 
or  tobacco  will  produce  death  through  coma.  In  coma 
the  patient  lies  on  his  back,  and  is  either  simply  insensible 
to  external  impressions,  or  has  a  confused  and  dull  percep- 
tion of  them,  with  restlessness  and  low  delirium.  In  such 
a  case  the  pulse  is  generally  strong,  the  pupils  dilated  and 
the  face  flushed.  Treatment  consists  in  placing  the  patient 
in  a  quiet,  reclining  position,  and  making  cold  applications 
to  the  head.  In  suffocation  from  gas,  use  artificial  respira- 
tion; when  due  to  drugs,  the  usual  antidote  may  be  given. 

Apoplexy  {Paralytic  Stroke). — Apoplexy  means  a  rup- 
ture of  a  blood  vessel  with  escape  of  blood  either  within  or 


UNCONSCIOUS    CONDITIONS  73 

upon  the  surface  of  the  brain,  the  pressure  resulting  in 
paralysis  of  one  or  a  group  of  muscles  of  one  or  more 
extremities.  The  affected  arm  or  leg  is  lifeless  and  cold, 
while  the  unaffected  parts  are  normal.  The  causes  are 
advanced  age,  with  over-exertion,  mental  and  physical  ex- 
citement, and  hardening  of  the  blood  vessels.  The  symp- 
toms are  a  flushed  face,  unconsciousness,  slow  pulse,  irreg- 
ular breathing  (stertorous),  eyes  insensible,  pupils  irregu- 
larly dilated.  Convulsions  may  occur.  Treatment  includes 
quiet,  in  a  horizontal  position.  Loosen  all  tight  clothing. 
Apply  cold  to  head  and  heat  to  the  extremities.  Hot  rectal 
injections  are  beneficial.    Do  not  use  stimulants. 

Asphyxia.— Asphyxia  is  loss  of  consciousness  by  exclu- 
sion of  air  from  the  lungs.  Causes  are  anything  that  would 
interfere  with  proper  respiration.  Only  a  scanty  supply 
of  air  may  be  admitted,  as  in  strangulation,  drowning,  chok- 
ing, or  disease  of  the  windpii)e;  and  again,  although  there 
may  be  every  capacity  of  respiration,  the  air  may  contain 
too  little  oxygen  in  proportion  to  other  elements.  As  the 
condition  of  asphyxia  advances,  in  drowning  or  otherwise, 
the  small  vessels  of  the  lungs  become  gorged  with  blood, 
which  the  heart  no  longer  has  power  to  force  freely  through 
them,  and  the  pulmonary  artery  and  the  right  side  of  the 
heart  become  filled  with  blood,  while  but  little  returns  to 
the  left  side  of  the  heart.  Treatment  is  to  fill  the  lungs 
with  fresh  air,  and  undoubtedly  the  most  efficient  method 
is  that  of  Dr.  Sylvester. 

Epileptic  Fits.— Epileptic  fits,  or  convulsions  or  falling 
fits,  are  periodic  convulsive  seizures.  They  are  due  to  some 
brain  disease,  such  as  pressure  caused  by  an  old  injury, 
or  are  the  result  of  some  previous  disease,  such  as  menin- 
gitis. The  symptoms  are  a  peculiar  cry,  followed  by  un- 
consciousness, grinding  of  the  teeth,  and  ^'frothing  at  the 
mouth."  Convulsive  seizures  of  the  face,  mouth,  arms  and 
legs,  and  rolling  of  the  eyeballs  are  followed  by  a  deep 
sleep.    The  patients  frequently  fall  unconscious  and  injure 


74  SHOCK   AND   MEDICAL    EMERGENCIES 

the  head  or  other  parts  of  the  body.  Treatment  is  to  pre- 
vent the  unfortunates  from  injuring  themselves,  and  to 
care  for  them  until  consciousness  returns.  Trephining, 
where  there  is  a  history  of  injury  or  disease,  is  an  advisable 
operation,  and  cures  result  in  a  majority  of  cases. 

Convulsions  of  Children.— Compulsions,  or  fits,  of  chil- 
dren are  muscular  paroxysms  due  to  irritation  of  the  nerv- 
ous system.  They  are  due  to  high  temjDerature  from 
teething  or  other  causes,  intestinal  irritation,  indigestion, 
worms,  constipation,  etc.  As  a  rule,  they  are  not  danger- 
ous, and  children  seldom  die  from  these  attacks.  S^mip- 
toms  associated  with  the  convulsions  are  fretfulness,  rest- 
lessness, gritting  the  teeth  and  stupor.  Muscles  of  the  face 
and  other  parts  of  the  body  twitch  and  may  become  stiff. 
The  limbs  move  in  various  directions.  The  pulse  is  rapid 
and  weak.  The  skin  is  cold  and  clammy,  with  perspiration 
in  the  later  stage.  Breathing  is  hurried  and  labored.  A 
IDeriod  of  quiet  may  precede  a  second  or  third  convulsion. 
Treatment  consists  in  promptly  immersing  the  jDatient  in  a 
bath  of  hot  water,  friction  to  the  extremities  and  the  body, 
with  cold  to  the  head.  Convulsions  in  children,  however, 
may  be  a  forerunner  of  meningitis  or  serous  inflammation 
of  the  sjDinal  cord  or  brain,  and  the  physician  should  as- 
sume responsibility  in  all  cases. 

Convulsions  from  Kidney  Bisesises.— Convulsions  from 
kidney  diseases  (Bright 's  disease,  etc.)  are  due  to  uremic 
poisoning  when  the  kidneys  fail  to  cast  off  the  waste  prod- 
ucts. Symptoms  are  dropsy  of  the  feet  and  other  parts  of 
the  body,  with  urine  scanty  or  suppressed.  Other  early 
sjmiptoms  are  headache,  nausea  and  vomiting.  The  convul- 
sions may  be  followed  by  coma  and  death.  Treatment  be- 
longs to  the  physician.  Quiet,  with  an  effort  to  produce 
sweating,  is  useful. 


CHAPTER  IX 


ASEPSIS   AND   ANTISEPSIS 


Asepsis  is  the  practice  of  thorough  cleanliness  in  a 
wound  already  sterile.  Sepsis  is  a  condition  where  specific 
or  infective  microbes  exist,  and  inflammation  in  some  de- 
gree always  follows.  Antisepsis  is  an  effort  to  destroy 
germs,  or  septic  conditions  already  present  in  wounds  or 
tissues,  by  means  of  some  germicidal  agent. 

If  wounds  are  already  sterile,  or  aseptic,  it  is  not  neces- 
sary that  germicides  or  chemicals  be  used  to  prevent  infec- 
tion. In  removing  a  tumor  where  no  wound  or  pus  exists, 
the  only  thing  necessary  to  keep  the  parts  sterile  is  to 
thoroughly  destroy  the  germs  which  may  be  on  the  hands  of 
the  operator  or  his  assistant  by  scrubbing  and  cleansing 
in  hot  water,  to  scrub  the  skin  about  the  proposed  incision 
with  hot  water,  and  to  boil  the  instruments  and  dressings 
at  least  twenty  minutes,  or  to  sterilize  them  by  the  use  of 
steam  or  dry  heat.  When  a  wound  has  already  been  in- 
fected, or  is  septic,  disinfectants  or  germ-destroying  agents 
must  be  used  to  produce  sterile  conditions.  It  is  now  neces- 
sary to  practice  antisepsis.  This  is  done  by  the  use  of  a 
flesh  brush  rubbed  over  the  skin  of  the  hands  and  arms 
under  running  water  or  in  water  as  hot  as  can  be  tolerated 
for  ten  or  twenty  minutes,  the  nails  being  thoroughly 
cleansed  with  a  tool,  as  germs  are  most  liable  to  be  lodged 
here,  the  skin  about  the  field  of  operation  being  given  the 
same  scrubbing;  or  by  the  use  of  certain  chemicals  as 
germicides,  when  it  is  thought  that  the  hot  water  has  not 
destroyed  all  germs. 

75 


76  ASEPSIS    AND    ANTISEPSIS 

Germicides.  — Germicidal  agents  are  numerous,  and 
their  jDOwer  to  destroy  microorganisms  varies  greatly. 
Those  in  most  common  use,  with  their  relative  values,  are 
as  follows : 

Tincture  of  lodhi  (U.  S.  P.)  is  one  of  the  most  effective 
antiseptics  known  to  surgery.  If  introduced  into  a  tissue 
containing  bacteria,  it  will  destroy  them  and  leave  the  tis- 
sue in  the  best  possible  condition  for  repair.  Its  use  in 
erysipelas  is  well  kno^vn.  It  has  the  power  of  penetrating 
tissue  and  in  aljraded  surfaces  it  is  absorbed  and  carried 
along  the  hmiphatic  vessels  originally  infected,  destroying 
the  germs. 

Mercuric  cliJorid  should  be  used  in  solution  strength 
from  one  to  six  hundred  to  one  to  eight  thousand.  For 
disinfecting  the  skin  one  to  two  thousand  is  generally  used, 
and  for  irrigating  wounds  one  to  four  thousand  is  suffi- 
ciently strong.  A  convenient  form  in  which  to  use  mercuric 
chlorid  in  private  practice  is  in  tablets  of  seven  and  one- 
half  grains  each,  prej)ared  by  the  chemist.  One  tablet 
added  to  one  quart  of  water  makes  a  one  to  two  thousand 
solution. 

Phenol  was  the  first  antiseptic  used  and  was  introduced 
by  Lister  in  1865.  The  usual  strength  for  the  hands  and 
skin  is  one  to  forty.  To  sterilize  instruments  they  should 
be  allowed  to  remain  in  solution  of  one  to  twenty  for  thirty 
minutes.  This  should  be  diluted  one  to  forty  with  hot  water 
before  the  instruments  are  handled,  as  so  strong  a  solution 
produces  anesthesia  of  the  skin,  and  otherwise  injures  it. 
For  irrigating  purposes  a  one  to  sixty  solution  should  be 
used.  Phenol  is  not  so  reliable  as  mercuric  chlorid  and 
may  produce  systemic  poisoning  and  local  gangrene,  and 
should  be  used  with  great  care.  For  deep  sterilization  it 
is  not  necessary,  the  reason  being  that  it  is  a  coagulant  and 
the  material  formed  by  its  action  constitutes  a  Avail  that 
prevents  it  from  penetrating  into  deeper  structures  of  the 
bone.     To  follow  the  use  of  phenol  with  alcohol,  as  is  ad- 


GERMICIDES  77 

vised,  to  prevent  too  great  corrosive  action,  is  hardly 
founded  upon  scientific  principles,  since  carbolic  acid  imme- 
diately coagulates  soft  tissues  and  absorption  from  such 
surfaces  is  not  to  be  feared.  If  good  comes  from  this  treat- 
ment it  must  be  due  to  the  alcohol  itself  rather  than  to  the 
phenol. 

Hydrogen  dioxid,  so  frequently  recommended  and  so 
commonly  used  by  the  average  surgeon,  has  no  place  in  the 
surgery  of  bones.  It  must  be  admitted  that  its  power  as 
a  parasiticide  is  in  its  action  upon  pus  or  the  products  from 
pathological  or  granulated  tissues,  and  that  effervescence 
is  evidence  that  pus  is  present.  As  a  matter  of  fact,  the 
moment  this  liquid  becomes  effervescent,  its  power  to  de- 
stroy bacteria  is  ended.  As  the  gas  thus  produced  must 
l^ush  out  in  every  direction,  it  carries  before  it  not  a  germi- 
cide, but  an  inert  bubble.  Hydrogen  dioxid  should  not  be 
used  in  a  cavity  because  of  its  effervescence,  for  it  distends 
the  tissue  and  these  inert  bubbles  carry  infective  germs, 
when  they  are  present,  deeper  into  the  tissues,  thus  infect- 
ing new  areas. 

For  the  preservation  and  sterilization  of  instruments 
and  suture  needles,  there  is  nothing  that  serves  so  well  as 
lysol.  This  is  especially  adapted  for  dental  purposes.  In- 
struments should  always  be  absolutely  free  from  germs,  so 
that  inoculation  of  one  patient  from  another  is  made  prac- 
tically impossible.  The  instruments  can  be  immersed  in 
lysol  for  months,  always  remaining  bright  and  clean.  The 
odor  is  not  so  objectionable  as  that  of  phenol  or  other  solu- 
tions. 

Other  antiseptics  are  zinc  cJilorid,  five  to  twenty  grains 
to  the  ounce,  and  potassium  permanganate,  a  dram  to  one 
ounce  of  water.  Some  useful  antiseptic  dusting  powders 
are  acetanilid,  ichthyol,  horic  acid,  and  bismuth  in  some 
form. 

Sterilization  of  Dressings  and  Instruments.— Materials 
used  in  the  performance  of  surgical  operations  are :  sponges 


78  ASEPSIS    AND    ANTISEPSIS 

made  of  cotton  or  gauze ;  gauze,  which  may  be  used  instead 
of  sponges,  or  for  the  purpose  of  drainage  and  packing  of 
wounds  and  for  external  dressings ;  absorbent  cotton  used 
for  external  dressings  and  as  sponges;  and  bandages  used 
to  secure  dressings  in  position. 

Absorbent  cotton  and  bandages  should  be  thoroughly 
sterilized  if  antiseptic  results  are  to  be  expected.  This  is 
accomplished  by  subjecting  the  materials  to  a  dry  heat  for 
twenty  minutes.  Operating  gowns,  towels,  instrument 
trays,  suture  and  ligature  materials,  as  well  as  instruments 
and  dressings,  should  be  sterilized  before  they  are  used. 

The  Operating  Room.— The  operating  room,  if  other 
than  one  constructed  for  the  purpose  in  a  modern  hospital, 
should  be  first  divested  of  carpets,  curtains,  and  draperies, 
then  sterilized  with  a  formaldehyde  lamp,  mercuric  chlorid 
or  sulphur  candles.  The  heat  of  the  room  should  be  from 
seventy  to  eighty  degrees  F.,  and  should  be  kept  uniform 
throughout  the  operation. 

The  Patient.— Preliminary  to  all  operations  the  skin 
about  the  field  of  operation  should  be  thoroughly  cleansed 
(all  hair  removed  by  being  shaved  sometime  before  opera- 
tion), and  the  patient  wrapped  in  sterile  dressings  com- 
posed of  gauze  and  cotton.  Just  before  operation  the  field 
of  operation  should  again  be  scrubbed  with  ether  soap  and 
irrigated  with  pure  alcohol,  or  it  may  be  painted  with  tinc- 
ture of  iodin. 

Sutures  and  Ligatures. — A  suture  is  a  stitch  made 
through  the  edges  of  a  wound  to  approximate  them  and 
hold  them  in  position  until  union  takes  place.  Materials 
used  in  making  sutures  are  silk,  catgut,  silkworm  gut,  kan- 
garoo tendon,  silver  and  iron  wire,  and  horsehair.  For  deep 
suturing,  catgut  and  kangaroo  tendon  are  used,  because 
they  are  absorbed  and  do  not  require  removal,  although 
silver  or  other  non-absorbable  material  may  become  en- 
cysted and  do  no  injury. 

Ligation  is  the  act  of  tying  a  blood  vessel,  lymphatic 


SUTURES    AND    LIGATURES  79 

or  other  pervious  duct  or  canal.  The  materials  used  for 
this  purpose  are  catgut,  silk  and  kangaroo  tendon.  Catgut 
is  to  be  preferred,  since  it  lasts  three  or  four  days  within 
the  tissues  and  is  sufficiently  permanent  to  insure  repair 
and  the  formation  of  a  permanent  clot  within  the  vessel 
ligated. 

Surgical  needles  must  be  kept  absolutely  sterile,  bright 
and  always  ready  for  use.  This  may  be  done  with  pure 
lysol  in  the  manner  jDreviously  described. 


CHAPTER  X 


GENERAL    DIAGXOSIS 


The  foundation  of  correct  diagnosis  must  be  a  tliorougli 
understanding  of  the  structural  changes  and  a  correct 
knowledge  of  the  relation  of  the  sjTnptoms  observed  to 
such  changes.  If  one  would  make  the  best  preparation  for 
this  work,  he  must  look  for  guidance  to  physiology,  to  nor- 
mal and  pathological  anatomy,  to  chemistry,  to  microscopy 
and  to  the  skiagraph  and  other  special  means  of  investiga- 
tion. 

Case  History.— A  systematic  method  of  examining  all 
patients  should  be  followed  and  a  written  record  kept  of 
the  findings.  Record  should  be  kept  in  about  this  order: 
Name,  age,  sex,  race,  nationality,  residence,  occupation, 
habits  or  mode  of  living,  married  or  single  (if  patient  is  a 
married  woman,  date  of  last  confinement  and  number  of 
previous  confinements);  age  of  i^arents,  if  living,  or,  if  dead, 
cause  of  death ;  condition  of  health  of  brothers  and  sisters, 
or,  if  dead,  cause  of  death ;  causes  of  death  of  deceased 
uncles  and  aunts.  As  complete  a  family  history  as  possible 
should  be  obtained.  The  aim  of  such  inquiries  as  these  is 
of  valuable  assistance  in  making  a  diagnosis  in  tuberculo- 
sis and  cancer. 

Investigation  of  previous  illnesses  may  throw  consider- 
able light  upon  the  case.  Inquire  particularly  as  to  rheu- 
matism and  syphilis.  While  it  may  occasionally  seem  in- 
delicate to  ply  suspicious  patients  with  questions,  if  spe- 
cific conditions  are  suspected,  an  appointment  may  be  made 
and  the  family  physician  consulted  in  the  meantime.  If  no 
physician  or  surgeon  has  been  seen,  it  is  the  duty  of  the 

80 


CASE    HISTORY  81 

dentist  to  advise  the  patient  to  see  one.  Especially  is  this 
true  of  conditions  about  the  oral  cavity.  Simple  ulcerations 
on  the  tongue  or  mucous  membrane  of  the  mouth  or  lif)s, 
which,  if  attended  to  early,  might  not  terminate  fatally,  are 
often  left  untreated  until  there  is  involvement  of  deep  struc- 
tures by  a  malignant  growth.  One  who  recognizes  a  grave 
condition  and  insists  upon  proper  treatment  is  entitled  to 
as  much  credit  as  the  operator,  whose  duty  is  clear. 

The  symptoms  include  the  date  of  the  beginning  of  the 
present  attack,  the  mode  of  seizure,  whether  sudden  or 
gradual,  etc.,  and  the  present  complaints  of  the  patient. 
Observe  the  general  nutrition  and  the  appearance  of  the 
face,  skin  and  tongue.  Note  the  character  of  the  pulse  and 
respiration.  Inquire  as  to  appetite,  thirst,  and  the  condi- 
tion of  the  bowels. 

Examination  of  the  hearty  lungs  and  other  organs  and 
recording  their  conditions  are  next  in  order.  With  all  the 
facts  of  the  case  then  at  hand,  one  is  able  to  judge  the  na- 
ture and  extent  of  the  diseased  structures,  or,  in  other 
words,  to  make  a  diagnosis. 

The  treatment  is  then  recorded  as  the  final  item  of  the 
case  history.  The  progress  of  the  disease  or  the  results  of 
treatment  should  be  recorded  from  time  to  time,  as  the 
patient  is  seen  at  the  office. 

How  to  Obtain  a  Complete  Knowledge  of  a  Disease.— 
In  making  a  study  of  diseases  it  is  necessary  that  the  sub- 
ject be  divided  into  several  heads,  so  that  it  can  be  taken 
up  systematically.  The  usual  course  of  study  is  as  follows : 
1.  Definition;  2.  Anatomy;  3.  History;  4.  Etiology;  5.  Pa- 
thology; 6.  Symptoms;  7.  Diagnosis;  8.  Differential  diag- 
nosis; 9.  Prognosis;  10.  Complications;  11.  Secpiels;  12. 
Mortality;  13.  Treatment. 

A  definition  often  leads  to  a  very  fair  understanding  of 
the  disease.  A  brief  review  of  the  anatomy  of  the  parts 
under  consideration  is  a  convenience  and  avoids  the  neces- 
sity of  making  further  research,  as  well  as  insures  knowl- 


82  GENERAL  DIAGNOSIS 

edge  of  the  subject  at  hand  which  might  otherwise  be  neg- 
lected.   W-e  must  know  the  normal  to  detect  the  abnormal. 

The  history  of  a  given  case  previous  to  the  onset  of 
active  symptoms  is  of  importance,  such  as  in  a  case  of  he- 
redity. Previous  injury  or  illness  usually  have  important 
bearing.  Etiology  is  the  cause  or  causes  which  precipitate 
the  onset  of  disease.  Pathology  is  a  study  of  the  tissue 
changes  during  the  course  of  the  disease. 

Symptoms  are  the  manifestations  of  disease.  Subjec- 
tive symptoms  are  those  appreciable  to  the  patient  alone, 
such  as  pain;  objective  symptoms  are  those  appreciable  to 
the  examiner,  such  as  swelling.  Diagnosis  is  the  naming  of 
the  disease  and  is  arrived  at  by  summing  up  all  of  the  pre- 
ceding conditions.  Differential  diagnosis  is  distinguishing 
the  disease  under  consideration  from  others  which  may 
have  symptoms  quite  similar. 

Prognosis  is  the  prediction  of  the  result  or  termination. 
Under  complications  a  study  is  made  of  the  diseases  or 
changes  which  might  develop,  secondary  to  the  original 
trouble  or  simultaneously.  Sequelce  include  all  remote  or 
subsequent  results.    Mortality  is  a  study  of  the  death  rate. 

Treatment  is  the  application  of  preventives  to  stop  a 
suspected  onset  or  to  cut  short  an  existing  disease,  and  the 
administration  of  restoratives  after  the  disease  has  run  its 
course.  Diseases  are  self-limited  when  they  run  a  regular 
course  requiring  a  definite  time,  after  which  spontaneous 
recovery  may  be  expected.  Typhoid  fever,  measles,  scarla- 
tina, smallpox,  etc.,  are  self-limited  diseases.  Many  condi- 
tions have  no  definite  course,  such  as  enlarged  glands,  ne- 
phritis, osteitis  or  periostitis. 

Diagnostic  Signs.— The  study  of  diagnostic  signs,  which 
are  in  reality  objective  symptoms,  is  not  given  in  detail  in 
this  book,  as  it  should  be  in  a  truly  medical  work.  For 
convenience  to  the  dental  student  the  subject  is  divided 
into  three  heads :  a,  medical  diagnosis ;  b,  physical  diagno-- 
sis;  c.  surgical  diagnosis  (or  examination). 


DIAGNOSTIC    SIGNS  83 

Medical  Diagnosis. — Medical  diagnosis  comprises  wliat 
may  be  learned  by  a  careful  general  inspection  of  the  pa- 
tient. Much  can  be  found  out  in  a  few  seconds  regarding 
the  health,  habits,  strength  and  mode  of  life  of  a  particular 
individual.  A  general  observation  of  all  patients  who  enter 
the  dentist's  office  is  necessary.  Shin  eruptions  are  to  be 
studied  and  at  least  approximately  made  out.  The  general 
health  of  the  patient  must  be  observed,  and  bilateral  phys- 
ical conformity  be  made  out.  The  color  of  the  skin  is  an 
index  to  general  health.  In  anemic  persons  the  skin  will 
be  very  white  and  bloodless.  In  advanced  cancerous  con- 
ditions there  will  be  a  sallow,  waxy  complexion.  When  the 
skin  is  yellow,  with  the  same  discoloration  of  the  eye,  liver 
trouble  is  to  be  suspected.  Puffiness  below  the  eyes  indicates 
kidney  trouble.  The  eyes  also  serve  as  an  index  to  the  con- 
dition of  health.  Protrusion  indicates  exophthalmic  goiter 
or  tumors  of  the  brain  and  antrum.  When  there  is  bilateral 
protrusion  goiter  may  be  suspected,  while  in  tumors  but 
one  eye  is  generally  involved.  When  one  lid  droops  it  is 
ptosis,  due  to  paralysis  of  the  third  nerve  from  brain 
lesions  or  trauma  along  the  trunk.  An  irregular  contrac- 
tion of  one  pupil  may  be  from  the  same  cause.  When  both 
pupils  are  contracted,  the  patient  is  under  suspicion  as  an 
opium  habitue.  When  both  pupils  are  widely  dilated  the 
patient  is  usually  under  the  influence  of  belladonna  or  has 
been  given  a  mydriatic  by  an  ophthalmologist.  Strabismus 
is  usually  of  no  particular  significance.  Glaring  eyes  indi- 
cate mania,  which  may  be  from  alcohol.  Bright  and  spark- 
ling eyes  are  seen  in  tuberculosis  and  in  persons  with  fever. 

The  tongue  may  be  coated,  due  to  a  disordered  stomach, 
mouth  or  throat  disease,  or  some  infectious  or  constitu- 
tional disease.  It  may  be  swollen,  due  to  inflammation ;  or 
ulcerated,  due  to  syphilis,  cancer  or  tuberculosis.  It  may 
be  bilaterally  or  unilaterally  paralyzed,  due  to  nerve,  or 
nerve  center,  involvement.  In  unilateral  paralysis  the 
tongue,  when  protruded,  points  toward  the  paralyzed  side. 


84  GENERAL  DIAGNOSIS 

The  lips  may  be  blue  (cyanosis),  due  to  lieart  or  lung 
disease.  They  are  frequently  the  seat  of  ulcerations,  in- 
cluding herpes  or  coldsores,  chancres  and  cancer.  Dysp- 
nea, or  shortness  of  breath,  may  be  caused  by  exertion, 
obesity  or  some  lung  or  heart  trouble. 

Swelling  or  edema  of  the  feet  and  ankles  is  suggestive 
of  heart,  kidney  or  liver  disease. 

Physical  Diagnosis. — Physical  examination  comjDrises 
an  examination  of  a  particular  organ  by  means  of  inspec- 
tion, mensuration,  palpation,  percussion,  auscultation  or 
combinations  of  the  same. 

Inspection  is  the  making  of  ocular  observation.  The 
principal  organs  of  the  thoracic  cavity,  the  heart  and  lungs, 
are  very  prone  to  pathological  changes,  some  of  which  ex- 
hibit well-marked  symptoms,  while  others  give  almost  no 
symjDtomatic  evidence  of  their  existence.  We  may  discover 
on  inspection  the  ^'alar  chest"  or  tuberculous  chest,  char- 
acterized by  the  prominence  of  the  scapulae  and  a  flattened 
condition  of  the  anterior  wall  of  the  thorax;  the  "pigeon 
chest"  and  beaded  ribs  of  rickets  and  deformities  caused 
by  curvature  of  the  spine;  and  the  ''barrel  chest"  of  em- 
physema. 

The  rate  of  respiration  in  an  adult  is  eighteen.  It  may 
range  from  forty  in  the  infant  to  from  fourteen  to  sixteen 
in  the  adult,  and  during  sleep  may  be  as  low  as  eight  or  ten 
per  minute. 

Mensuration  is  making  measurements  and  computing 
bilateral  symmetry. 

Palpation  is  the  use  of  the  sense  of  touch.  It  is  per- 
formed by  the  use  of  the  whole  hand  applied  to  the  surface 
of  the  thorax  or  by  the  use  of  the  tips  of  the  fingers  only, 
giving  information  as  to  the  vocal  fremitus,  the  location 
and  character  of  the  cardiac  pulsation  and  the  friction  rub 
of  pleuritis  and  pericarditis. 

Percussion,  either  by  the  use  of  the  fingers  or  the  per- 
cussion hammer  and  pleximeter,  is  the  production  of  sounds 


DIAGNOSTIC    SIGNS  85 

by  pounding  or  percussing  a  part,  and  is  probably  the  most 
useful  of  all  means  in  the  diagnosis  of  pathological  changes 
in  the  thoracic  viscera,  aiding  as  it  does  in  the  discovery 
of  solidified  areas  in  the  lungs,  which  elicit  a  pulmonary 
resonance.  The  bowels  distended  with  gas  elicit  a  tympanic 
resonance.  At  the  margin  of  the  liver  or  heart  there  is 
dullness.  Where  there  is  absence  of  sound,  as  over  the 
centers  of  the  liver  or  heart,  it  is  known  as  flatness.  Pul- 
monary resonance,  elicited  by  percussion,  is  the  normal 
sound,  described  as  a  clear,  resonant  note,  heard  most  dis- 
tinctly below  the  clavicle  and  in  the  axillary  space.  It  in- 
dicates a  normally  inflated  lung.  When  the  normal  note  is 
not  elicited  and  a  dullness  is  found,  it  is  indicative  of  con- 
solidation of  the  lung,  abscess,  or  pleuritic  effusion.  When 
dullness  is  substituted  by  flatness,  which  is  an  absence  of 
all  i3ulmonary  resonance,  it  shows  that  the  lung  is  entirely 
displaced  by  pleuritic  effusion  or  is  completely  consolidated. 
As  percussion  extends  from  the  right  lung  downward  over 
the  liver,  the  sounds  change  to  dullness  at  about  the  fifth 
rib  and  to  flatness  as  the  lower  margin  of  the  lung  is  passed 
and  the  liver  reached. 

Tympanic  note  is  found  over  cavities  in  the  lungs  from 
abscess  or  phthisis.  In  pneumothorax  and  emphysema  the 
normal  pulmonary  resonance  is  exaggerated.  A  metallic 
note  is  produced  by  percussing  over  large  cavities  with 
smooth  walls.  A  cracked-pot  resonance,  or  the  bruit  da 
pot  fela  of  the  French,  is  heard  when  the  act  of  percus- 
sion forces  the  air  out  of  a  lung  cavity  through  a  restricted 
opening. 

Auscultation  is  the  act  of  making  johysical  examinations 
with  the  ear,  which  may  be  aided  by  the  use  of  a  stetho- 
scope, or  a  phonendoscope.  The  sound  heard  during  nor- 
mal respiration  is  known  as  pure  vesicular  breathing. 
Vesicular  breathing  may  be  exaggerated  in  difficult  respira- 
tory acts,  in  bronchitis,  hjqDersecretion  of  mucus,  etc.  It 
may  be  prolonged  or  accelerated  during  asthma,  emphy- 


86  GENERAL  DIAGNOSIS 

sema,  etc.  Jerking  vesicular  breathing  is  found  in  painful 
affections,  such  as  pneumonia,  pleurisy  and  beginning  pul- 
monary tuberculosis.  Bronchial  breathing  is  heard  over 
cavities  communicating  with  the  large  bronchial  tube,  in 
consolidation  and  compression  of  the  lungs  from  whatever 
cause — pneumonia,  tuberculosis,  gangrene  and  tumor.  Am- 
phoric breathing  is  a  blowing  sound,  indicating  the  pres- 
ence of  large  cavities  with  smooth  walls,  and  is  generally 
associated  with  metallic  note  on  percussion.  Rales  are  ab- 
normal sounds  heard  during  respiration,  caused  by  the 
passing  of  the  air  over  mucus.  They  are  dry  when  they 
whistle  and  indicate  viscid  or  scanty  secretion,  found  in 
catarrhal  conditions.  Moist  rales,  which  may  be  small,  me- 
dium size,  or  large,  indicate  a  thin,  abundant  secretion,  the 
size  depending  upon  the  size  of  the  bronchi  in  which  they 
are  found.  The  largest  rales  indicate  cavities.  Crepitant 
rales  are  usually  heard  on  deep  inspiration  and  are  caused 
by  the  sudden  separation  of  the  walls  of  the  alveoli  and 
bronchioles,  previously  collapsed.  They  are  heard  during 
the  first  stage  of  pneumonia,  pulmonary  edema,  and  atel- 
ectasis. Hippocratic  succussion  is  a  metallic  splashing 
sound  heard  upon  vigorous  shaking  of  the  patient,  and  indi- 
cates the  presence  of  a  cavity  containing  air  and  fluid. 

Auscultation  also  elicits  exaggerated  or  lessened  vocal 
sounds,  indicating  a  change  of  certain  conducting  media  of 
vibrations  of  the  spoken  voice.  Exaggerated  vocal  reso- 
nance is  an  intensified  sound  and  is  known  as  bronchophony, 
or  pectoriloquy.  When  it  resembles  the  bleating  of  a  goat, 
it  is  known  as  egophony.  Pleurisy  with  effusion,  empyema, 
which  is  a  purulent  pleuritic  effusion,  and  consolidation  of 
the  lungs,  all  destroy  the  normal  lung  sounds  in  both  per- 
cussion and  auscultation.  Friction  sounds  are  heard  dur- 
ing dry  pleurisy  and  in  pericarditis. 

Eruptions  may  be  discovered  on  the  surface  of  the  abdo- 
men, such  as  the  "rose  spots"  of  typhoid  fever  and  pur- 
pura.   By  lightly  palpating  the  abdomen  in  such  a  way  as 


DIAGNOSTIC    SIGNS  87 

not  to  cause  contraction  of  the  abdominal  muscles,  one 
can  make  out  many  conditions  which  under  more  vigorous 
or  rough  handling  would  not  be  apparent.  It  is  sometimes 
necessary  to  resort  to  the  use  of  an  anesthetic  on  account 
of  the  rigidity  of  the  abdominal  muscles.  The  examination 
should  be  begun  with  the  patient  on  his  back.  He  should 
next  be  placed  on  one  side  and  then  on  the  other,  and  gentle 
palpation  practiced  in  each  of  these  positions.  This  pro- 
cedure is  of  great  value  in  examining  for  movable  kidney 
and  enlarged  or  displaced  liver,  kidney  or  spleen,  and  tu- 
mors. The  tenderness  due  to  peritonitis  and  the  localized 
tenderness  due  to  gastric  ulcer  and  appendicitis  are  found 
on  deeper  pressure.  Percussion  will  demonstrate  the  size 
of  the  liver  and  spleen  and  their  position,  and  the  accumu- 
lation of  gases  or  fluids  in  the  abdomen,  all  of  which  are 
common  conditions  resulting  from  a  number  of  pathological 
changes. 

When  deemed  necessary,  we  have  access  to  chemical 
analysis  of  urine  for  the  presence  of  albumen,  sugar,  bile, 
blood  and  other  abnormal  constituents.  Microscopic  ex- 
aminations are  made  for  tube  casts,  epithelium  from  the 
bladder,  ureter  and  kidneys,  alkaline  and  acid  crystals  of 
the  various  alkaline  salts  and  uric  acid,  the  presence  of 
tubercle  bacilli,  gonococci  and  other  pathogenic  bacteria. 


CHAPTER  XI 

DISEASES    AND    INJUEIES    OF    THE   VASCULAE   SYSTEMS 

In  making  a  study  of  the  pathological  conditions  of  the 
vascular  systems,  it  is  convenient  to  consider  them  as  fol- 
lows : 

The  heart: 

Diseases  of  valves. 

Diseases  of  muscles. 

Diseases  of  pericardium. 
Blood  vessels: 

Diseases  of  walls. 

Diseases  of  contents. 

Aneurism  and  varix. 

Hemorrhage.     (See  page  58.) 

Tumors. 
Lymphatics : 

Diseases. 

Tumors. 

THE  HEART 

Heart  Sounds.— The  heart  has  two  sounds.  The  first, 
represented  by  the  syllable  lub,  is  heard  during  systole, 
and  is  caused  by  the  closure  of  the  mitral  and  tricuspid 
valves  and  the  rush  of  the  blood  from  the  heart  through  the 
aorta  and  pulmonary  artery.  It  is  synchronous  with  the 
apex  beat  and  carotid  pulse.  There  is  also  a  muscular 
element  in  the  first  sound  caused  by  the  contraction  of  the 
heart  muscles  and  the  impact  of  the  heart  against  the  chest 
wall.  The  second  sound  is  represented  by  the  syllable  dub, 
and  is  heard  during  diastole,  being  caused  by  the  closure 


THE    HEART 


89 


of  the  aortic  and  pulmonic  valves,  and  by  the  blood's  rush- 
ing from  the  auricles  to  the  ventricles. 

Diseases  of  the  Valves.— Every  one  of  the  sets  of  valves 
of  the  heart  is  subject  to  two  varieties  of  disease,  viz.:  (1) 
Eegurgitation  or  insufficiency,  where  the  valves  fail  to  close 
and  the  blood  rushes  back  to  the  cavity  which  it  just  left. 


Fig.  9. — Showing  Where  the  Heart  Sounds  Are  More  Intense,     a.  Pul- 
monic valve,     b.  Aortic  valve,     c.  Mitral  valve,     d.  Tricuspid  valve. 


and  (2)  stenosis,  or  a  failure  of  the  valves  to  properly  open, 
thus  resisting  the  free  passage  of  the  blood  current. 

Mitral  regurgitation  is  the  most  common  valvular  lesion. 
It  is  systolic  in  time,  and  is  heard  most  distinctly  over  the 
apex  of  the  heart.  The  murmur  is  transmitted  in  the  di- 
rection of  the  regurgitated  blood  or  toward  the  left  axilla 
and  angle  of  the  scapula. 


90  THE    VASCULAR    SYSTEMS 

In  mitral  stenosis  the  murmur  is  presystolic  in  time 
(occurring  in  the  latter  part  of  diastole),  is  heard  best  a 
little  within  the  apex  of  the  heart  and  is  not  transmitted. 
The  murmur  is  prolonged  and  rough  in  character  and  in- 
creases in  intensity  as  it  approaches  the  first  sound  and 
ends  in  a  sharp  systolic  shock. 

Aortic  regurgitation. — The  murmur  is  diastolic  in  time. 
It  is  caused  by  the  blood's  rushing  back  into  the  left  ventri- 
cle from  the  aorta.  It  is  most  distinctly  heard  over  the 
base  of  the  heart  at  the  second  intercostal  space  on  the  right 
side,  and  is  transmitted  toward  the  apex. 

Aortic  stenosis  is  heard  during  systole,  and  the  sound 
is  transmitted  along  the  course  of  the  aorta,  sometimes  to 
the  carotids  and  subclavian. 

Tricuspid  regurgitation  occurs  during  systole,  and  is 
caused  by  the  blood's  flowing  back  from  the  right  ventricle 
to  the  right  auricle.  It  is  heard  during  the  first  sound.  The 
abnormal  sound  is  heard  throughout  the  length  of  the  heart 
back  of  the  sternum  slightly  to  the  left  of  the  median  line. 

Lesions  of  the  pulmonary  valves  are  quite  rare  and  al- 
ways congenital.  Regurgitation  occurs  during  diastole  and 
stenosis  during  systole.  The  sounds  are  most  distinctly 
heard  over  the  base  of  the  heart,  and  are  transmitted  in  the 
direction  of  the  blood  current. 

Other  Affections  of  the  Heart.— In  addition  to  the  val- 
vular lesions  of  the  heart  the  following  conditions  are  men- 
tioned and  briefly  described,  so  that  the  dentist  may  de- 
termine whether  his  patient  has  a  normal  heart  before  the 
administration  of  an  anesthetic. 

Pericarditis  is  an  inflammation  of  the  serous  lining  of 
the  pericardium.  It  is  usually  associated  with  rheumatism 
or  other  acute  diseases.  Pericardial  effusion  frequently 
follows.  The  principal  symptoms  are  pain  over  the  heart, 
dyspnea  and  embarrassment  of  the  heart's  action  during 
recumbency. 

Endocarditis  is  an  inflammation  of  the  endocardium  or 


THE    HEART  91 

endothelial  lining  of  the  internal  portion  of  the  heart.  It 
most  frequently  attacks  the  valves,  resulting  in  heart  mur- 
murs. Pain,  difficulty  of  breathing  and  frequency  of  pulse 
are  symptoms.  It  is  generally  of  rheumatic  origin,  al- 
though it  may  occur  as  a  sequela  of  the  acute  fevers  and 
of  gonorrhea. 

Hypertrophy  of  the  heart  is  an  enlargement  of  the  or- 
gan, usually  compensatory,  or  because  of  some  mechanical 
obstruction  demanding  more  than  normal  work,  and  the 
muscle  develops  up  to  the  demands  made  upon  it. 

Dilatation  of  the  heart  usually  follows  hypertrophy  and 
is  evidence  that  the  muscle  can  no  longer  do  its  work  and 
is  degenerating.  Fatty  degeneration  is  an  increased  de- 
posit of  fat  and  a  corresponding  diminution  of  the  muscu- 
lar elements.  Fibroid  degeneration  is  a  replacement  of 
the  normal  histological  tissue  by  tendonous  connective 
tissue. 

Angina  pectoris,  also  known  as  stenocardia,  is  charac- 
terized by  severe  pain  in  the  heart,  radiating  about  the 
back,  shoulder  and  arm,  accompanied  with  the  fear  of  im- 
pending death.  It  is  indicative  of  sclerosis  of  the  coronary 
arteries,  and  is  a  grave  condition. 

The  pulse  heat  is  indicative  of  the  heart's  action,  and 
the  radial  artery  is  usually  selected  for  examination,  al- 
though any  other  artery  may  be  used.  The  average  rate 
is  seventy-two  per  minute,  with  a  range  of  from  sixty  to 
eighty  in  health.  In  children  the  normal  range  is  from 
ninety  to  one  hundred  and  twenty  per  minute.  As  old  age 
advances,  the  heart  beat  increases  in  frequency.  The  pulse 
is  increased  in  frequency,  or  accelerated,  during  muscular 
exertion,  excitement  and  acute  disease,  or  during  exhaus- 
tion. It  usually  increases  in  frequency  as  death  ap- 
proaches. Certain  drugs,  such  as  ammonia,  and  alcoholic 
products,  accelerate  the  pulse. 

Retardation  of  the  pulse  may  depend  upon  weakness 
of  the  heart  or  valvular  disease  or  undue  stimulation  of  the 


92  THE    VASCULAR    SYSTEMS 

vagus  by  drugs,  sucli  as  opium,  veratrum  viride,  etc.  A 
quick  pulse  is  a  result  of  shortened  systole,  and  may  be 
accompanied  by  either  increased  or  diminished  frequency. 
Irregular  pulse  is  found  in  degenerative  changes  m  the 
heart  muscle,  as  myocarditis,  and  in  cardiac  lesions.  We 
speak  of  alternating  pulse  where  only  every  other  heart 
beat  is  strong.  The  pulse  is  large  when  it  is  full  and 
bounding,  small  when  it  is  Aveak,  hard  when  it  is  not  easily 
comj)ressed,  soft  when  easily  compressed,  and  thready 
when  it  is  so  rapid  and  weak  as  to  be  scarcely  perceptible. 

DISEASES  AND   INJURIES   OF  THE  ARTERIES  AND  VEINS 

The  blood  vessels  are  composed  of  three  coats:  (1)  Ad- 
ventitia,  an  external  elastic  covering  composed  principally 
of  white  connective  tissue  with  elastic  fibers;  (2)  media, 
composed  of  two  layers  of  non-striated  muscular  fibers, 
viz.,  circular  and  longitudinal;  (3)  the  intima,  which  is  the 
serous  lining  of  the  cavity  of  the  vessels.  It  is  covered 
internally  with  endothelium.  The  structure  of  the  veins  is 
practically  the  same  as  that  of  the  arteries,  except  that  they 
are  thinner,  offer  less  resistance,  and  collapse  after  being 
emjDtied. 

Diseases  of  the  Walls. — Diseases  of  the  walls  may  be 
classified  as  inflammatory  when  an  acute  process  begins 
in  the  walls  or  in  an  adjacent  tissue  and  extends  to  the 
arterial  wall.  VThen  the  external  coat  alone  is  involved  it 
is  knoAATi  as  periarteritis,  when  the  pathological  change  is 
in  the  muscular  coat  as  mesarteritis,  and  when  the  serous 
membrane  alone  is  involved  as  endarteritis.  Maier  has  de- 
scribed a  nodular  variety  of  disease  which  not  only  en- 
larges without,  but  A\ithin,  obstructing  the  lumen  of  the 
vessel.  When  such  areas  are  infected  with  pyogenic  bac- 
teria, suppuration  is  the  result.  In  addition  to  the  acute 
processes,  pathological  changes  may  be  caused  by  syiDhilis 
or  tuberculosis,  either  as  a  primary  or  secondary  condition. 


THE   ARTERIES   AND   VEINS  93 

Fatty  degeneration  of  the  arterial  wall,  especially  of  the 
aorta  and  large  vessels,  develops  as  a  complication  of  simi- 
lar degeneration  in  other  organs. 

Calcareous  degeneration  or  atheroma  is  a  degenerative 
change  of  the  vessels,  usually  of  the  muscular  coat,  in 
which  the  wall  becomes  hard,  resulting  in  impairment  of 
functional  activity.  It  may  be  diffused  or  local.  The  dif- 
fused variety  involves  all  the  smaller  vessels  throughout 
the  body,  so  that  they  feel  hard  under  the  finger.  The  usual 
elasticity  disappears  from  the  pulse,  and  as  the  disease 
advances,  the  impulse  is  entirely  lost.  It  is  a  condition 
found  in  advanced  life  or  as  the  result  of  disease  or  alco- 
holism. Since  all  vessels  are  similarly  affected,  the 
skin  of  the  hands,  feet,  etc.,  becomes  dry  and  harsh,  and 
the  intellect  gTadually  impaired,  so  that  patients  may  be- 
come helpless  invalids  for  several  years  before  death.  Lo- 
cal atheroma  is  confined  to  a  single  artery  or  organ,  such 
as  a  coronary  artery  of  the  heart.  Sudden  deaths  are 
more  frequently  due  to  atheromatous  changes  than  to 
valvular  heart  disease  as  popularly  understood. 

Phlebitis  is  an  infection  of  the  veins.  It  may  run  an 
acute  course,  as  seen  after  contusions  or  infections  of  the 
wall  directly  or  secondary  to  an  adjacent  pathological 
change.  A  sub-acute  form  sometimes  appears  after  par- 
turition, known  as  phlegmasia  alba  dolens,  popularly  known 
as  '^milk  leg."  It  is  not  usually  fatal,  but  may  terminate 
in  death.  It  extends  over  several  months.  A  later  compli- 
cation is  chronic  ulcer  of  the  leg,  a  most  painful  and  an- 
noying condition.  The  treatment  for  chronic  phlebitis,  or 
a  resultant  ulcer,  is  ferric  chlorid  in  twenty-drop  doses 
after  eating.  For  the  ulcer  antiseptic  powder,  such  as  boric 
acid,  answers  quite  well.  Strapping  with  adhesive  straps 
is  excellent.  Phlebitis  may  be  caused  by  gout,  syphilis, 
tuberculosis,  or  may  be  a  sequela  of  any  of  the  acute  dis- 
eases, especially  rheumatism.  In  all  varieties  of  phlebitis 
the  affected  parts  should  be  elevated  above  the  heart  so 


94  THE    VASCULAR    SYSTEMS 

that  the  pressure  of  the  blood  column  may  be  removed. 
Clots  frequently  form,  especially  when  the  disease  is  of  the 
sinuses  of  the  brain,  in  which  locality  the  treatment  is 
prompt  operation  for  their  removal. 

Diseases  of  the  Contents.— Abnormal  conditions  within 
the  vessel  wall  or  of  the  liquid  contents  are  considered  in 
works  on  pathology  under  the  following  heads :  Thrombo- 
sis and  Embolism. 

Aneurism. — An  aneurism  is  a  circumscribed  dilatation 
of  one  or  more  coats  of  a  vessel  communicating  with  its 
cavity.  The  causes  are  trauma,  such  as  a  puncture  or  a  rup- 
ture of  its  wall,  and  dilatation  of  the  wall  due  to  some 
pathological  changes.  Aneurisms  are  classified  according  to 
their  shape,  as  tubular,  fusiform,  sacculated  and  dissecting; 
according  to  their  origin,  as  idiopathic  and  traumatic;  or 
according  to  their  structure,  as  true,  when  the  coats  consti- 
tute the  sac,  and  false,  when  the  coats  have  been  perforated 
and  the  aneurismal  walls  are  composed  of  the  surrounding 
tissues.  Other  forms  are  recognized  as  arterio-venous 
aneurism,  known  as  aneurismal  varix,  when  the  blood 
passes  directly  from  an  artery  to  a  vein.  A  varicose  aneur- 
ism occurs  when  a  sac  intervenes  between  an  artery  and  a 
vein.  Varix,  or  varicose  veins,  is  a  dilated  condition  of 
veins  usually  found  in  the  superficial  vessels  of  the  leg. 
The  symptoms  of  aneurism  are  pulsation,  fluctuation,  thrill, 
bniit  and  compressibility.  A  differential  diagnosis  must 
be  made  from  tumors  of  all  kinds,  which  develop  from  other 
tissues,  and  from  tumors  of  the  vessels  themselves.  The 
course  is  necessarily  chronic  and  the  termination  in  all 
deep  aneurisms  of  large  vessels  is  fatal.  When  aneurisms 
are  found  in  the  vessels  of  the  extremities  or  upon  the  sur- 
face, proper  treatment  promises  recovery.  Fatal  termina- 
tion is  due  to  rupture  and  exsanguination,  to  pressure  of 
the  sac  upon  important  structures,  as  the  trachea,  esopha- 
gus, nerves,  heart,  etc. 

The  treatment  includes  compression,  manipulation,  gal- 


THE   ARTERIES   AND   VEINS  95 

vanopunctnre,  acupuncture,  ligation  of  various  kinds,  and 
enucleation.  The  methods  and  merits  of  these  various  pro- 
cedures make  a  long  story  which  may  be  found  in  works 
on  general  surgery. 

Tumors. — Angiomata  are  tumors  composed  principally 
of  blood  vessels.  Park  groups  them  into  three  classes:  (a) 
Nevus,  or  birthmark,  or  port-wine  mark,  assumes  the  shape 
and  color  of  fruit  or  other  object.  This  is  called  capillary 
angioma  and  is  supposed  to  be  due  to  an  increase  in  num- 
ber and  size  of  the  capillaries  and  smaller  blood  vessels 
throughout  the  tumor.  Angiomata  are  congenital,  or  ap- 
pear soon  after  birth.  They  may  occur  on  any  part  of  the 
body,  and  when  in  the  skin  of  the  face  or  mucous  membrane 
of  the  lii^s  or  conjunctivae  are  most  objectionable,  marring 
the  personal  appearance  of  the  individual.  Otherwise 
they  have  no  clinical  significance,  remaining,  as  a  rule,  the 
same  size  throughout  life,  though  occasionally  increasing 
or  diminishing. 

(b)  Cavernous  angiomata  are  sometimes  known  as  erec- 
tile tumors,  because  they  contain  dilated,  tortuous  and 
thickened  veins  and  cajoillaries.  The  blood  forced  into  the 
tumors  through  the  distension  results  in  a  denseness  not 
found  in  the  first  variety.  They  are  usually  subdermal 
or  are  connected  with  the  skin,  and  are  quite  common  in 
the  thyroid  gland  and  liver. 

(c)  Circoid  aneurisms,  or  j)lexiform  angiomata,  are  com- 
posed of  dilated  blood  vessels,  are  larger  in  size  than  either 
of  the  former  varieties,  and,  when  they  are  located  over  a 
firm  bony  base,  as  the  scalp  or  forehead,  the  line  of  the  ves- 
sel leaves  a  distinctly  outlined  depression  upon  the  bone. 
They  are  generally  found  over  the  forehead,  face  and  scalp, 
and  mucodermal  junctions,  but  appear  also  in  other  parts 
of  the  body.  The  treatment,  as  accepted  to-day,  is  of  two 
kinds:  First,  electrolysis,  which  consists  in  introducing 
into  the  tumor  a  negative  needle,  while  the  j^ositive  pole  is 
on  some  part  of  the  body,  the  idea  being  to  coagulate  the 


96  THE    VASCULAR    SYSTEMS 

contents  of  the  tumor  and  finally  obliterate  it  by  cicatriza- 
tion; and  second,  the  more  radical  course  of  comjDlete  enu- 
cleation under  an  anesthetic.  This  is  quite  a  bloody  pro- 
cedure unless  all  vessels  leading  to  the  involved  area  are 
ligated  before  removal. 

LYMPHATICS 

The  lymphatics  are  subject  to  injury,  infections,  dila- 
tation, occlusion  and  tumors.  Injuries  are  seldom  so 
extensive  as  to  require  attention,  since  anastomosis  is  so 
comi^lete  that  several  trunks  may  be  severed  and  no  ill  con- 
sequences result.  Lymphangitis,  or  infection  of  the  vessels, 
is,  as  a  rule,  secondary  to  an  adjacent  infection  beyond. 
One  or  many  glands  are  involved,  and  in  many  instances  a 
chain  extends  toward  the  thorax.  The  glands  or  ganglia 
become  perceptibly  enlarged  and  tender.  Acute  infections 
of  the  glands  of  the  neck  are  seen  in  scarlatina,  diphtheria 
and  acute  diseases  about  the  mouth,  abscesses  of  the  teeth, 
pyorrhea,  etc. 

Chronic  enlargement  of  the  glands  is  seen  most  fre- 
quently in  syphilis  and  tuberculosis.  Syphilitic  lymph 
nodes  in  the  neck,  groin,  axillary  and  epitrochlear  spaces 
are  common  conditions.  Abscess  of  the  glands  results  from 
any  acute  infection  in  any  part  of  the  body.  Tuberculous 
enlargements  of  the  glands  frequently  suppurate  and  re- 
quire incision. 

Obstruction  of  the  lymph  channels  follows  infections 
producing  uniform  enlargement  of  a  part  or  extremity 
known  as  elephantiasis.  This  enlargement  of  a  leg  may 
cause  it  to  reach  many  times  its  normal  size. 

Treatment  for  acute  infections  includes  cold  or  heat, 
as  may  be  selected,  with  counter-irritants,  such  as  iodin 
and  the  thermocautery.  Suppurating  glands  should  be  in- 
cised, curetted  and  packed.  The  so-called  scrofulous  gland, 
known  to  the  laity  as  *' King's  Evil,"  is  either  a  tubercu- 


LYMPHATICS  97 

Ions  or  syphilitic  infection.  Syphilitic  glands  should  not 
be  incised. 

Lymphangioma  resemble  angioma  in  structure,  the  dif- 
ference being  that  one  involves  the  blood  vessels  and  the 
other  the  lymph  vessels.  The  most  common  form,  and  that 
which  is  most  frequently  found  in  the  field  of  dental  opera- 
tions, is  that  form  developing  from  the  surface  of  the 
tongue  in  papillae  varying  in  size  and  number.  When 
they  are  large  and  numerous  they  abnormally  enlarge  this 
organ  and  cause  the  condition  known  as  macroglossia,  or, 
when  the  lip  is  involved,  as  macrocheilia. 

Treatment  consists  in  the  use  of  electrolysis,  as  de- 
scribed above,  but  the  electric  current  does  not  coagulate 
lymph  as  it  does  blood,  the  benefit  coming  from  the  absorp- 
tion of  the  tissues.  Aspiration,  followed  by  injections  of 
iodin,  is  frequently  successful.  When  these  methods  fail, 
or  when  prompt  result  is  desired,  extirpation  by  the  knife 
is  followed  by  repair  and  cure.  Macroglossia  and  macro- 
cheilia are  best  treated  by  radical  operation. 


PAET  II 
ORAL   SURGERY 


CHAPTER  XII 

GENERAL   USTTEODUCTIOlSr 

Introductory  to  the  study  of  the  mouth,  a  review  of 
some  points  of  its  anatomy  and  general  pathology  will  pre- 
pare the  student  to  more  readily  appreciate  the  pathological 
conditions  of  this  cavity  as  they  are  found  in  practice. 

Pathology  is  the  same,  whether  of  the  mouth  or  of  other 
parts  of  the  body;  hence,  to  understand  general  tissue 
changes  means  an  appreciation  of  mouth  lesions.  There 
is  a  difference,  however,  since  the  oral  cavity  contains  more 
diverse  and  complex  tissues  than  any  other  part  of  the 
body. 

The  many  functions  performed  in  the  mouth  make  the 
demands  upon  the  various  tissues  more  exacting,  yet  the 
repair  by  natural  and  artificial  means  is  vastly  better  than 
in  any  other  of  the  complex  visceral  systems  of  the  body. 
Its  proximity  to  so  many  structures  of  major  importance, 
such  as  the  accessory  sinuses  of  the  skull,  the  brain,  the 
organs  of  respiration  and  deglutition,  and  the  anatomical 
structures  connected  with  the  special  senses,  makes  the  care 
of  the  mouth  of  great  importance. 

The  mucous  membrane  is  a  light  pink  in  children  and 
in  anemic  persons.  It  is  also  light  in  color  in  old  age.  Dur- 
ing vigorous  adult  life  it  is  a  deep  pink,  approaching  a  red. 
The  blood  supply  which  controls  the  color  is  also  influenced 
by  inflammatory  changes  about  the  mouth,  which,  in  turn, 
influence  the  blood  current,  producing  congestion;  or  a 
hyperemia  may  result  from  a  reflex  vasomotor  disturbance 
due  to  remote  changes,  such  as  neuralgia,  etc.    Localized 

101 


102  GENERAL    INTRODUCTION 

discolorations  of  the  mucous  membrane  over  the  alveolar 
process  are  suggestive  of  localized  internal  infections  of  a 
subacute  or  chronic  character,  and  the  teeth  should  be 
thoroughly  examined  in  such  cases. 

Disturbances  Due  to  Dentition.— Dentition  is  a  frequent 
cause  of  general  disturbance.  From  the  fourth  to  the  elev- 
enth month  children  begin  to  cut  their  teeth,  cotemporane- 
ous  with  which  is  the  secretion  of  a  very  largely  increased 
amount  of  saliva.  "Playthings,"  alternately  in  the  mouth 
and  on  the  floor,  contaminate  the  saliva  with  all  varieties 
of  microorganisms  which,  when  taken  into  the  stomach, 
cause  indigestion  and  intestinal  derangements,  such  as 
diarrhea,  etc. 

Symptoms  of  a  general  nature  which  are  the  result  of 
difficult  dentition  are  restlessness,  fretfulness,  disturbed 
sleep,  occasional  elevation  of  temperature,  vomiting,  colic, 
and  diarrhea.  Any  of  the  infective  fevers  may  develop 
during  teething,  due  to  the  absorption  from  the  alimentary 
canal  of  the  germs  which  are  taken  into  the  system  by  the 
excessive  salivation. 

Many  nervous  manifestations  have  been  recorded  as 
dependent  upon  reflex  spasm,  caused  by  the  pressure  of  a 
tooth  in  its  effort  to  pass  through  the  soft  tissues  overlying 
the  alveolar  process.  If  these  nerve  symptoms  are  very 
severe  and  there  is  evidence  of  many  teeth  coming  through 
at  the  same  time,  it  is  good  practice,  when  the  symptoms 
persist,  to  incise  a  very  highly  distended  gum  over  an 
erupting  tooth. 

It  is  a  curious  fact  that  the  tooth  makes  its  way  through 
the  bone  without  causing  any  reflex  nerve  symptoms.  It 
is  also  a  well-known  fact  that  teeth  which  do  not  pass 
through  the  alveolar  process  in  the  normal  direction,  the 
course  being  diverted,  produce  many  varieties  of  reflex 
neuroses,  the  cure  of  which  is  only  effected  by  the  removal 
of  the  offending  tooth.  (Attention  to  this  has  been  called 
in  the  pages  on  ''Reflex  Neuroses.") 


ORAL    HYGIENE  103 

Many  skin  lesions  are  observed  during  the  period  of 
dentition,  due  either  to  reflex  neurosis  or  to  intoxication 
following  intestinal  fermentation,  viz.,  dermatitis  and 
eczema;  and  other  eruptions  of  the  face  and  neck  are  di- 
rectly traceable  to  the  excessive  flow  of  saliva  from  the 
mouth  to  the  skin. 

Owing  to  the  presence  of  the  great  number  of  bacteria 
found  in  the  saliva  of  teething  children,  their  diet  should 
be  very  carefully  considered  and  an  effort  should  be  made 
to  eliminate  as  far  as  possible  materials  furnished  to  the 
baby  for  teething  and  amusement,  which  might  contain 
great  quantities  of  these  germs.  While  it  would  be  a  diffi- 
cult matter  to  entirely  avoid  such  practices  without  constant 
watching,  the  danger  would  be  greatly  reduced  by  per- 
mitting children  to  use  only  such  playthings  as  can  be 
sterilized. 

Oral  Hygfiene.— Cleanliness  of  the  mouth  is  of  the  great- 
est importance  if  the  vitality  of  the  teeth  is  to  be  prolonged 
and  if  those  various  constitutional  conditions  which  are 
undoubtedly  traceable  to  mouth  diseases  are  to  be  avoided. 
This  subject  presents  itself  under  several  heads :  first, 
mouth  lesions  traceable  to  constitutional  diseases,  and,  sec- 
ond, constitutional  or  systemic  pathological  changes  de- 
pendent upon  lesions  within  the  oral  cavity. 

Under  the  first  head  are  found  the  various  ulcerative 
conditions,  to  be  considered  under  the  head  of  stomatitis, 
also  bleeding  of  the  gums  associated  with  rickets,  scorbu- 
tus and  cretinism.  Mouth  lesions  are  not  uncommon  as  a 
sequel  to  typhoid  and  the  eruptive  fevers. 

Users  of  tobacco  and  alcohol,  and  people  who  are  care- 
less about  using  a  toothbrush  regularly  are  liable  to  have 
mouth  lesions.  Pyorrhea  and  other  ulcerative  conditions 
are  frequently  found  in  individuals  who  have  syphilis  as 
an  underlying  factor  or  who  have  a  tuberculous  lesion  in 
some  other  part  of  the  body. 

General  diseases  are  so  frequently  the  cause  of  lesions 


104  GENERAL   INTRODUCTION 

in  the  mouth  that  the  subject  has  attracted  a  great  aniount 
of  attention  during  the  last  few  years.  Miller,  in  his  won- 
derful studies  of  the  bacteria  of  the  mouth  and  their  conse- 
quences, has  placed  this  subject  upon  a  scientific  basis. 
Black  and  many  others  have  made  innumerable  cultures  of 
the  contents  of  the  oral  cavity  and  have  found  that  the 
saliva  possesses  toxic  properties,  due  to  the  presence  of 
microorganisms.  Many  of  the  bacteria  producing  general 
diseases  are  constantly  found  in  the  mouth.  Frankel's 
IDueumococcus,  several  varieties  of  streptococci,  as  well  as 
diphtheritic  bacilli,  are  sometimes  found  in  the  mouths  of 
healthy  jDcrsons. 

In  all  cases  where  any  variety  of  ulceration  is  found, 
such  as  pyorrhea,  etc.,  the  bacterial  culture  is  carried  on 
more  rajoidly,  and  constitutional  infection  necessarily  re- 
sults where  the  vitality  is  reduced.  These  bacteria  are 
taken  into  the  stomach,  producing  fermentation  and  ab- 
sor^^tion,  and  consequent  constitutional  symptoms. 

Netter  found  that  ten  per  cent,  of  all  mouths  contain 
some  variety  of  streptococcus,  and  that  the  diplococcus  of 
pneumonia  is  found  in  fifteen  per  cent,  of  healthy  mouths. 
Shriver  states  that  75  per  cent,  of  apical  abscesses  contain 
the  diplococcus  of  pneumonia,  and  Valpain  produced  septi- 
cemia by  inoculating  animals  with  saliva  from  healthy 
men. 

The  constant  presence  of  bacteria  and  their  products 
in  the  mouth  sometimes  exerts  a  deleterious  influence  upon 
the  normal  mucous  membrane,  inhibiting  taste  and  appetite 
and  producing  a  condition  spoken  of  as  "disordered  stom- 
ach." 

Many  cases  of  infection  following  dental  operations  are 
due  to  self-infection,  the  open  wound  left  by  the  extraction 
of  a  tooth  furnishing  a  convenient  point  of  entrance  for 
bacteria.  Death  from  septic  causes  is  not  uncommon  after 
major  operations  on  the  mouth,  the  most  common  condition 
being  septic  pneumonia.     One  of  the  commonest  and  most 


ORAL    HYGIENE  105 

important  effects  of  carious  teeth  is  the  enlargement  of  the 
cervical  lymphatic  glands,  and  tonsillar  enlargement  may  be 
due  to  the  same  cause.  Ludwig's  angina,  characterized  by 
diifuse  cellulitis  of  the  region  between  the  lower  jaw  and 
the  hyoid  bone,  is  in  some  cases  due  to  infections  from  a 
carious  tooth.  The  bacteria  of  the  mouth  may  also  pro- 
duce remote  infections,  such  as  malignant  endocarditis, 
osteomyelitis,  etc.  The  mouth  may  be  the  means  of  trans- 
mitting disease  to  others,  the  transmission  of  syphilitic 
virus  by  means  of  saliva  and  instruments  employed  in  the 
mouths  of  syphilitics  being  of  frequent  occurrence. 

Alveolar  abscess  in  its  various  forms  results  in  prac- 
tically all  of  the  bone  destructions  not  traceable  to  the  exan- 
themata, constitutional  and  specific  diseases.  Symptoms 
of  constitutional  infection  resulting  from  mouth  intoxica- 
tion are  mild  elevation  of  temperature,  rigors,  loss  of  appe- 
tite and  consequent  loss  of  weight,  languor,  and  headaches, 
which  in  some  instances  may  persist  for  many  months. 

In  a  recent  case,  a  very  suspicious  sinus,  following  the 
extraction  of  an  upper  lateral,  produced  the  above  condi- 
tions, the  most  prominent  symptom  being  persistent  head- 
aches for  four  years.  The  correction  of  the  carious  con- 
dition -removed  the  source  of  infection  and  restored  the 
patient  to  perfect  health.  It  is  a  well-known  fact  that  a 
large  proportion  of  malignant  diseases  of  the  mucous  mem- 
brane of  the  mouth  and  the  maxillary  bones  are  caused  by 
neglected  teeth.  Sharp  projections  of  enamel  excoriate  or 
abrade  the  mucous  membrane  every  time  the  tongue  or 
mandible  is  moved,  and  the  constant  irritation  furnishes 
a  field  for  absorption  or  is  the  cause  of  cell  proliferation, 
and  an  epithelioma  results. 

The  question  of  development  of  the  teeth,  or  rather  fail- 
ure of  the  teeth  to  properly  develop,  resulting  in  defects  of 
various  types  which  have  been  classified  under  the  heads  of 
atrophy,  indented  or  Hutchinson  teeth,  is  one  which  has 
attracted  attention  for  a  great  many  years.     It  remained 


106  GENEEAL   INTRODUCTION 

for  Dr.  G.  V.  Black  of  Chicago,  in  his  very  exhaustive 
study  of  the  subject,  to  disprove  the  theory  of  Hutchinson 
teeth  as  diagnostic  of  hereditary  syphilis.  Indeed,  Dr. 
Black  points  out  that  Magitot,  a  French  surgeon,  ques- 
tioned the  correctness  of  Hutchinson's  statement  regarding 
the  subject,  and  that  Hutchinson  himself  yielded  the  point 
so  far  as  to  say  that  inherited  syphilis  was  a  frequent 
cause,  but  for  many  years  he  had  held  that  this  type  of 
teeth  was  always  caused  by  inherited  syphilis. 

The  most  frequent  cause  of  defective  teeth,  according 
to  Black,  is  improper  feeding  of  children,  which  will  result 
in  the  cupping  of  teeth  or  an  atrophy  of  the  middle  lobe. 
Serious  sickness  at  any  given  time  in  a  child's  life  may  re- 
sult in  a  defect  in  the  line  of  all  of  the  teeth,  advanced  up  to 
a  certain  point  of  development,  and  which  will  be  shown 
on  the  crowns  of  these  teeth,  as  illustrated  in  Fig.  10. 

The  exhaustive  researches  made  by  Black,  which  ap- 
pear in  his  work  on  operative  dentistry,  place  the  subject 
in  such  a  position  that  no  one  dares  to  question  the  cor- 
rectness of  his  statements.     He  says : 

"I  have  followed  this  subject  pretty  carefully  ever  since 
Hutchinson  wrote,  adding  observation  after  observation 
until  I  have  arrived  at  the  conclusion  that  there  is  no  spe- 
cial form  of  disease  that  is  especially  blamable  for  this  af- 
fliction, but  that  any  form  of  disease  which  seriously  inter- 
feres with  nutrition  is  liable  to  bring  about  this  result,  i.  e., 
that  it  is  not  the  particular  form  of  disease,  but  that  it  is 
the  condition  of  malnutrition  that  is  the  cause,  no  matter 
what  the  disease  which  has  induced  that  condition.  I  have 
seen  several  cases  of  typical  Hutchinson  teeth  that  were 
certainly  in  no  way  connected  with  a  syphilitic  taint  of  any 
kind." 

Complications  of  Extraction.— Occasionally  there  results 
from  extraction  of  teeth  certain  major  conditions  requiring 
extraordinary  measures  for  their  management  and  control. 

During  extraction  of  teeth  many  accidents  occur  requir- 


COMPLICATIONS    OF    EXTRACTION  107 

ing  the  services  of  a  surgeon.  Fracture  of  the  mandible 
or  a  considerable  portion  of  the  maxilla  may  occur,  requir- 
ing replacement  or  wiring.  Slipping  forceps  or  excavator 
may  perforate  important  structures  and  injure  an  artery 
or  nerve,  resulting  in  dangerous  complications.  Dislocation 
of  one  or  both  sides  of  the  mandible  may  occur.  Probably 
the  most  disastrous  complication  of  extraction  is  to  have 
the  extracted  tooth,  or  more  likely  a  root,  slip  from  the 
forceps,  drop  into  the  pharynx  and  be  carried  along  with 
the  inspired  air  into  the  air  passages.  Such  a  disaster 
requires  prompt  tracheotomy  or  death  may  follow  within 


Fig.  10. — Atkopht  Marks  on  Teeth.     (Dr.  Black.) 

a  few  hours.  When  a  tooth  or  root  is  swallowed  it  need 
not  cause  alarm,  since  it  usually  passes  through  the  ali- 
mentary canal  without  difficulty.  Other  complications,  such 
as  injury  to  the  nerve,  lip  or  tongue,  by  the  forceps  or  an 
irregular  tooth,  perforation  of  the  antrum  by  a  tooth's  be- 
ing pushed  forward  by  the  forceps,  or  forcing  a  root  into 
an  abscess  cavity,  are  not  infrequent.  Such  complications 
may  be  followed  by  severe  and  lasting  changes  unless  prop- 
erly treated. 

Under  the  head  of  antral  disease,  extractions  have  been 
given  as  a  cause,  and  in  the  chapter  on  fractures  it  is 
learned  that  extractions  may  destroy  the  continuity  of  the 
mandible.  Hemorrhage  following  extractions,  esx)ecially 
of  molars,  is  sometimes  alarming.  In  one  case  reported, 
exsanguination  and  syncope  was  the  hemostatic  that 
stopped  the  flow  of  blood  and  saved  the  patient.  In 
' '  bleeders ' '  extractions  should  not  be  made  until  the  patient 
is  told  of  the  danger  if  he  does  not  already  understand  it. 


108  GENERAL    INTRODUCTION 

Almost  every  dentist  sees  severe  hemorrhage  after  extrac- 
tion, but  ordinarily  experiences  little  difficulty  in  control- 
ling it. 

A  most  satisfactory  method  of  controlling  hemorrhage 
is  to  make  a  pad  large  enough  to  cover  the  entire  lacerated 
surface,  and  thick  enough  to  extend  well  above  the  remain- 
ing teeth.  Place  it  in  position  and  have  the  patient  close 
the  jaws.  The  continued  pressure  controls  the  bleeding. 
If  pressure  fails,  plug  the  sockets  with  cotton  saturated 
with  adrenalin  chlorid  solution. 

Reflex  Neuroses  from  the  Teeth.— From  time  to  time, 
during  the  past  one  hundred  years,  surgeons  and  dentists 
have  written  articles  upon  the  subject  of  reflex  neuroses, 
with  siDecial  reference  to  the  irritating  factor's  being  some 
lesion  in  the  alveolar  process.  Richter,  in  1795,  recognized 
the  connection  between  dental  irritations  and  affections 
of  the  eye  and  ear,  and  is  very  emphatic  in  his  opinions. 
In  1817,  Bier  reported  a  case  where  a  contracted  visual 
field  was  entirely  corrected  by  the  extraction  of  a  carious 
tooth.  Jonathan  Hutchinson,  of  London,  was  the  first  to 
prepare  a  systematic  paper  upon  this  subject,  and  he  re- 
ported many  cases  of  defective  vision,  both  in  adults  and 
infants,  that  were  entirely  cured  by  the  correction  of  patho- 
logical conditions  found  in  the  mouth.  Wright  reported  a 
corneal  ulcer  which  was  cured  by  the  extraction  of  a  carious 
upper  molar  on  the  same  side.  Deafness  and  other  impair- 
ment of  hearing  have  been  corrected  after  the  removal  of 
impacted  teeth  and  other  abnormal  conditions.  Trismus, 
or  spasmodic  ankylosis,  is,  in  the  majority  of  cases,  caused 
by  impacted  third  molars  and  may  be  due  to  other  dental 
irregularities  and  diseases. 

The  author  has  recently  operated  upon  a  case  of  impac- 
tion where  four  teeth  were  found  in  various  parts  of  the 
mandible  and  maxilla  in  irregular  position  in  a  man  aged 
about  forty,  who  had  been  suffering  for  several  years  with 
a  condition  very  much  resembling  writer's  cramp  of  the 


REFLEX  NEUROSES  FROM  THE  TEETH     109 

right  arm,  with  a  special  wrist  drop,  the  symptoms  of  which 
disappeared  after  the  repair  of  the  mouth  from  the  opera- 
tion. Another  case  in  practice  is  that  of  a  woman  about 
thirty  years  of  age  who  was  suffering  with  a  very  severe 
form  of  neuralgia  in  the  neighborhood  of  the  right  hip, 
which  might  be  likened  to  sciatica.  Shortly  after  the  case 
was  seen  she  made  a  call  upon  her  dentist  to  have  her  teeth 
put  into  proper  condition.  An  abscessed  tooth  was  found 
and  treated  and,  immediately  thereafter,  the  pain  in  the 
hip  entirely  disappeared.  Several  of  such  cases  have  been 
reported  during  the  past  twenty-five  years. 

More  recently  many  papers  and  one  book  have  appeared 
on  the  subject  of  insomnia  and  nerve  strain  dependent  upon 
ulcerations  about  the  teeth  and  impacted  teeth.  Upson,  in 
his  book,  reports  his  investigations  in  an  insane  asylum 
of  Ohio,  stating  that  he  found  quite  a  number  of  the  in- 
mates suffering  with  impacted  teeth,  alveolar  abscess, 
pyorrhea,  and  other  ulcerative  conditions  in  the  mouth, 
the  correction  of  which  entirely  restored  their  reason 
so  that  they  were  cured  and  discharged  from  the  hos- 
pital. 

Dementia  precox,  melancholia,  mania,  hypomania,  hys- 
teria and  neurasthenia  are  all  included  in  the  list  of  general 
conditions  occasionally  dependent  uj^on  impaction  of  teeth, 
requiring  operation.  The  investigations  carried  on  by  phy- 
sicians interested  in  the  juvenile  courts  have  demonstrated 
that  many  cases  of  degeneracy,  as  indicated  by  thieving  and 
other  acts  of  incorrigibility,  have  been  due  to  impacted 
teeth,  and,  where  no  other  cause  can  be  found,  it  is  now 
customary  to  suspect  the  teeth  and  to  have  X-ray  pictures 
taken  of  the  face. 

In  a  recent  paper  by  Van  Doom,  a  number  of  cases  of 
insomnia,  nerve  strain  and  other  hysterical  manifestations 
are  referred  to  which  were  found  to  be  due  to  the  improper 
filling  of  root  canals  and,  in  an  instance  or  two,  the  death 
of  pulp   after  the  filling  of  a  tooth  had   so  affected  an 


110    ,  GENEEAL   INTRODUCTION 

individual  as  to  produce  general  neurosis  of  a  marked 
type. 

Muscular  spasms  in  the  form  of  torticollis  and  contrac- 
tion of  the  masseter  or  temporal  muscles  resembling  true 
tetanus  have  been  reported,  the  muscles  remaining  in  a  con- 
dition of  tonic  spasm  until  the  irritant  was  removed.  Clonic 
spasms  of  muscles  and  groups  of  muscles  are  attributed  to 
the  same  cause,  and  Ramskill  reports  one  case  of  epilepsy 
due  to  a  decayed  molar  tooth. 

Neuralgias  of  the  shoulder,  arm,  neck  and  ear  and  of 
every  part  of  the  head  have  disappeared  after  the  removal 
of  carious  or  suppurating  teeth  or  abscesses  of  the  roots  of 
teeth.  The  pressure  of  artificial  teeth  against  a  nerve 
terminal  caused,  in  one  case  reported  by  Mr.  Bell,  a  severe 
neuralgia  of  the  forearm,  which  disappeared  after  the  pres- 
sure was  removed.  Salter  states  that  a  young  woman  suf- 
fered a  paralysis  of  the  arm  from  a  carious  wisdom  tooth, 
and  upon  its  extraction  the  arm  power  immediately  re- 
turned. Paralysis  of  the  seventh  nerve,  or  Bell's  palsy, 
and  paralysis  of  muscles  remote  from  the  face  have  re- 
sulted from  diseases  of  the  teeth. 

Nutrition  has  been  perverted  as  a  result  of  irregularly 
developed  teeth,  resulting  in  superficial  ulceration  of  the 
tongue  and  cheek,  and  even  of  the  skin  over  the  neck, 
shoulder  and  arm.  Deafness,  visual  disturbances  and  pu- 
pillary irregularities,  which  appeared  to  be  dependent  upon 
grave  lesions  in  the  brain,  promptly  cleared  up  after  a  cor- 
rection of  defects  in  the  teeth. 

Some  most  troublesome  complications  may  be  associated 
with  the  eruption  of  the  molar  teeth.  This  is  especially 
true  of  the  third  molar,  since  in  fifty  per  cent,  of  cases  there 
is  scant  room  for  the  tooth  to  erupt,  and  its  course  through 
the  alveolus  is  at  variance  with  the  normal,  making  pres- 
sure upon  important  nerves  and  resulting  in  temporary 
ankylosis  of  the  mandible.  Impaction  of  a  lower  molar 
may  cause  infection,  resulting  in  abscess  formation  and 


KEFLEX  NEUROSES  FROM  THE  TEETH      111 

ulceration  tlirough  the  skin  over  the  angle  of  the  jaw,  and 
the  resulting  sinus  cannot  be  closed  until  the  offending 
tooth  is  removed.  A  probe  passed  through  the  opening 
from  the  interior  usually  comes  in  contact  with  the 
tooth,  thus  readily  making  out  the  true  nature  of  the 
trouble. 


CHAPTEE    XIII 

ALVEOLAE  ABSCESS  AND  ITS  MOEE  GEAVE  CONSEQUElsrCES 

The  causes  which  may  be  factors  in  producing  extension 
of  pathological  changes  in  the  teeth  may  be  enumerated  as 
infective  and  non-infective.  The  7i on-infective  conditions 
are  such  factors  as  arsenic  left  in  the  periapical  tissues 
after  treatment,  the  filling  of  a  root  canal  with  an  irritating 
substance,  or  the  protrusion  of  a  canal  filling  through  the 
apical  foramen.  A  frequent  error  in  this  direction  is  made 
following  the  adjustment  of  a  crown  where  the  drilled  hole, 
instead  of  following  the  root  canal  of  the  tooth,  passes  out 
through  the  side  and  into  the  bony  tissue,  the  operator 
assuming  that  he  is  entirely  within  the  tooth  structure. 
Arsenic  left  in  the  tissue  in  such  condition  cannot  be  re- 
moved and  must  necessarily  result  in  a  very  low  grade  of 
osseous  disintegration,  which  will  eventually  destroy  con- 
siderable tissue. 

A  second  variety  of  non-infective  disease  is  that  follow- 
ing cystic  degeneration  of  the  root  of  a  tooth  around  the 
apical  foramen.  In  this  instance  the  little  sac  which  is  so 
frequently  seen  upon  the  root  of  a  tooth  develops  where 
there  is  little  resistance  to  the  accumulation  of  serum  in 
the  bony  tissues.  It  is  quite  infinitesimal  in  the  beginning, 
being  increased  in  microscopic  quantities,  as  occurs  in  all 
tissues  which  are  undergoing  the  process  of  repair.  In 
other  words,  the  serum  is  that  of  repair  which,  instead  of 
making  its  escape  as  we  see  it  in  surface  wounds,  accumu- 
lates in  some  instances  to  a  considerable  amount.  In  a 
recent  case  it  was  the  size  of  an  English  walnut,  encroach- 

112 


ALVEOLAR    ABSCESS  113 

ing  upon  tlie  nose,  antrum  and  the  external  plate,  causing 
considerable  of  a  tumefaction  over  the  right  side  of  the 
face.  Operation  showed  that  the  roots  of  the  lateral  and 
cuspid  projected  into  the  cavity  for  about  one-eighth  of  an 
inch,  the  vessels  and  nerves  of  the  apex  of  the  teeth  being 
entirely  destroyed  and  the  roots  being  roughened.  In  an- 
other instance,  three  lower  incisors  and  the  right  cuspid 
projected  into  a  cyst  the  size  of  the  last  joint  of  the  thumb. 

A  frequent  cause  of  pyorrhea  and  abscess  of  the  mandi- 
ble in  the  neighborhood  of  the  angle  is  the  almost  constant 
presence  of  putrefactive  bacteria  in  the  pocket  which  is 
always  found  immediately  back  of  the  posterior  lower 
molar.  As  the  corresponding  upper  molar  articulates  with 
this  tooth  on  its  posterior  cusp,  the  tendency  is  to  push 
foods  back  into  this  pocket. 

Infective  diseases  include  all  of  those  more  serious  de- 
structions of  bone  included  under  the  head  of  alveolar  ab- 
scess and  necrosis. 

The  course  of  extension  of  disease  to  the  tissues  around 
the  teeth  depends  upon  the  cause,  and  in  those  cases  where 
there  is  no  infection  the  development  must  be  very  slow, 
extending  over  a  period  of  several  years,  the  tumor  gradu- 
ally increasing  in  size  and,  in  many  cases,  spontaneously 
opening  or  being  incised  by  the  surgeon. 

In  the  infective  varieties,  the  course  depends  upon  the 
variety  of  germ  which  is  found  as  a  causative  factor.  In 
some  instances,  a  very  insignificant  alveolar  abscess  de- 
velops quite  rapidly  about  the  root  of  a  tooth,  spontane- 
ously opens,  and  a  sinus  is  left,  which  may  be  without  pain 
or  marked  symptoms — indeed,  attracting  very  little  atten- 
tion. This  variety  is  dependent,  as  a  rule,  upon  a  chronic 
form  of  germ,  such  as  the  staphylococcus  pyogenes  aureus. 
If  the  disease  is  dependent  upon  streptococcic  infection,  it 
runs  a  more  rapid  course,  involving  a  great  area  of  bone  in 
the  course  of  a  week. 

A  girl  aged  ten  had  a  decayed  first  molar  which  was 


114  ALVEOLAR  ABSCESS 

treated  for  what  appeared  to  be  an  acute  disease  confined 
entirely  to  the  tooth.  In  the  course  of  forty-eight  hours  the 
infection  had  broken  under  the  periosteum  on  the  lingual 
side  of  the  mandible.  When  it  was  incised  one  week  later, 
about  four  ounces  of  pus  of  very  offensive  character  and 
of  a  greenish  color  escaped  and  the  inferior  margin  of  both 
sides  of  the  body  of  the  bone  was  bare  from  the  angle  to 


Fig.  11. — Case  of  Alveolar  Abscess. 

the  mental  foramen.  Such  a  lesion  is,  of  course,  dependent 
apon  streptococcic  infection.     (Figure  11.) 

That  alveolar  abscess  is  the  cause  of  many  of  the  grave 
and  more  serious  pathological  changes  about  the  oral  cav- 
ity, there  can  be  no  doubt.  It  has  been  ascribed  by  many 
authorities  to  traumatic  pericementitis,  resorption  of  the 
roots  of  permanent  teeth  and  death  of  the  dental  pulp  and 
the  resultant  apical  pericementitis. 

Pathology.— Whether  infection  really  comes  from  the 
tooth  cavity  or  from  the  apical  tissues,  the  course  is  about 
the  same.  The  product  of  the  decomposition  forces  its 
way  through  the  root  canal  to  the  bone,  where  it  becomes 


PATHOLOGY  115 

active,  resulting  in  abscess  formation.  The  pressure  dis- 
tends the  peridental  membrane,  which  thus  becomes  the 
wall  of  the  abscess.  The  first  change  is  quite  small,  begin- 
ning in  the  form  of  an  infiltrate,  which  later  liquefies.  This 
change  involves  the  tissues  immediately  around  the  apex  of 
the  root,  either  destroying  or  promoting  the  resorption  of 
the  bone.  The  process  of  the  destruction  is  in  the  direction 
of  the  least  resistance  from  the  root  involved,  which  ap- 
pears to  be  on  the  buccal  side  of  the  alveolar  abscess.  The 
destruction  continues  to  the  surface  of  the  bone,  when 
external  manifestations  of  the  abscess  are  present,  that  is, 
a  fluctuating  tumor.  The  process  of  destruction  is  in  pro- 
portion to  the  activity  of  the  germ  responsible  for  the  dis- 
ease. The  liquid,  after  escaping  through  the  compact  struc- 
ture of  bone,  goes  underneath  the  periosteum  and,  in  the 
case  before  referred  to,  the  lower  half  of  the  body  of  the 
right  side  of  the  mandible  was  involved.  Eventually  it 
breaks  through  the  periosteum  into  the  surrounding  tissues 
and  finally  through  the  mucous  membrane  into  the  oral 
cavity  in  maxillary  disease,  and  from  the  body  of  the  man- 
dible through  the  skin  anywhere  from  the  symphysis  to  the 
angle,  being  deflected  downward  by  the  platysma  muscle 
and  its  fascia.  Opening  of  the  abscess  cavity  either  spon- 
taneously or  by  incision  naturally  leads  the  inexperienced 
practitioner  to  believe  that  he  has  reached  the  end  of  the 
disease.  If,  however,  the  sinus  persists,  we  have  then 
established  what  is  known  as  a  chronic  alveolar  abscess. 

A  fact  not  to  be  forgotten  in  consideration  of  all  dis- 
eases of  the  bones  of  the  face,  where  a  fistulous  opening 
which  has  persisted  for  a  few  months  is  found,  is  that  a 
tooth  must  be  reckoned  with  as  the  cause.  If  a  tooth  has 
been  extracted  and  the  wound  does  not  heal  and  the  sinus 
does  not  close,  there  is  undoubtedly  the  root  of  another 
tooth  denuded  of  its  membrane  and  standing  bare  in  the 
cavity. 

Surgeons  recognize  low-grade  chronic  infections  as  a 


116  ALVEOLAR  ABSCESS 

cause  of  serious  constitutional  conditions,  such  as  head- 
ache, usually  intermittent  in  type,  loss  of  appetite,  loss  of 
weight,  and  general  impairment  of  vitality.  The  dentist 
should  have  in  mind  the  fact  that  an  alveolar  abscess,  even 
without  pain  and  without  extensive  discharge,  can  produce 
the  same  variety  of  symptoms.  The  absorption  of  the 
smallest  quantity  of  toxins  from  an  infected  area  may  pro- 
duce very  perceptible  constitutional  disturbances. 

It  is  proper  here  to  call  attention  to  that  variety  of 
alveolar  abscess  which  has  for  its  only  method  of  exit  the 
root  of  a  tooth  through  the  pulp  chamber.  In  such  cases 
considerable  of  a  cavity  may  be  found  around  the  apex, 
with  symptoms  enumerated  above.  The  amount  of  destruc- 
tion of  bone  ranges  from  the  smallest  cavity  to  the  complete 
destruction  of  the  mandible.  In  one  instance  a  low  form  of 
destruction  extending  through  a  period  of  months,  destroy- 
ing little  bone,  occurs ;  in  others  a  great  quantity  of  bone  is 
destroyed  before  the  infection  can  be  controlled. 

It  often  occurs,  after  the  extraction  of  a  tooth  where 
considerable  destruction  has  taken  place,  that  the  socket  is 
emptied  of  its  usual  blood-clot  and  that  the  labial  or  the 
buccal  process,  or  both,  is  denuded  of  periosteum.  This 
means  that  the  blood  supply  has  been  cut  otf  from  the  bone 
and  that  if  it  is  left  without  operative  interference  it  will 
exfoliate,  the  size  of  the  piece  of  bone  depending  entirely 
upon  the  limitation  of  blood  supply. 

In  these  cases  there  is  usually  considerable  suppuration, 
possibly  parasitic  infection  and  always  saphrophytic  putre- 
faction. If  the  case  has  extended  over  a  period  of  a  few 
weeks,  possibly  five  or  six,  there  will  be  much  granulated 
tissue  developed  around  the  margin  of  the  wound,  which  is 
Nature's  effort  to  build  up  a  granuloma  sufficiently  large 
to  cover  the  bone.  Such  granulation  tissue  is  called  proud 
flesh,  and  may  be  mistaken  for  a  polypus,  fibroma  or  papil- 
loma. 

Treatment  in  such  cases  consists  in  one  of  two  proce- 


PATHOLOGY  117 

(lures:  First,  a  radical  operation  by  chiseling  and  cutting 
away  the  dead  bone  back  to  the  point  where  it  bleeds,  when 
the  remaining  periosteum  and  soft  tissues  are  approxi- 
mated and  the  cavity  obliterated,  if  possible,  with  sutures ; 
second,  treatment  with  antiseptics  and  packing,  a  conserva- 
tive and  expectant  plan,  and  one  which  is  adopted  too  fre- 
quently. In  this  event,  there  will  eventually  be  exfoliation 
of  that  part  of  the  bone  which  has  been  deprived  of  its  nu- 
trition. These  fragments  may  be  removed  without  any  dif- 
ficulty, or  occasionally  it  may  be  necessary  to  enlarge  the 
opening  through  the  mucous  membrane,  when  the  fragment 
which  is  found  detached  may  be  removed. 

The  question  as  to  what  occurs  after  an  alveolar  abscess 
has  existed  for  considerable  time  and  the  bone  has  been  de- 
stroyed for  an  area  of  about  one-quarter  of  an  inch  upward 
from  the  root  of  the  tooth,  one-half  an  inch  long,  and  one- 
quarter  of  an  inch  horizontally,  is  one  for  speculation.  We 
have  already  stated  that  it  is  in  just  this  variety  of  cavity 
that  blood-clot  organization  occurs,  yet  we  also  see  cases 
where  there  is  a  sinus  which  remains  open  for  several 
months  or  a  year,  that  will  open,  close  and  spontaneously 
open  again  after  a  period  of  possibly  months  or  years,  to 
again  close  in  the  same  way  and  possibly  open  again.  This 
is  not  uncommon  in  the  management  of  old  tuberculous 
joint  diseases.  The  explanation,  where  this  occurs,  is  that, 
while  the  external  orifice  may  close,  there  is  a  small  cavitj^ 
left  somewhere,  and  since  its  wall  is  neither  covered  with 
epidermis  nor  epithelial  cells,  but  with  granulation  tissue, 
it  must  necessarily  throw  out  a  little  of  the  serum  of  repair 
as  well  as  a  few  leucocytes  and  reparative  cells.  As  this 
fluid  is  in  small  quantities  and  is  retained,  it  will  event- 
ually distend  the  original  cavity,  force  its  way  along  the 
sinus,  and  finally  break  through  at  the  point  of  original 
exit. 

It  cannot  be  claimed  in  any  of  these  cases  that  such  a 
cavity  would  fill  in  with  new  bone.    After  the  extraction  of 


118  ALVEOLAR  ABSCESS 

teeth  in  the  alveolar  process,  there  is  not  only  blood-clot 
organization  but  an  approximation  of  the  alveolar  ridges, 
and  eventually  an  absorption  and  collapse  of  the  entire  al- 
veolar framework,  so  that  it  is  brought  nearer  to  the  cen- 
tral canal  of  the  bone  in  the  case  of  the  mandible  and 
nearer  to  the  floor  of  the  antrum  and  the  nose  in  the  case 
of  the  maxilla. 

It  is  believed  that  blood-clot  organization  does  take 
place  and  that  real  bone  tissue  is  thrown  out  to  fill  in  these 

spaces  just  as  surely  as  new 
bone  is  thrown  out  after  a 
fracture.  The  conduct  of  the 
blood  cells  is  based  upon  the 
amount  of  stimulation  they 
receive,  and  there  is  no  rea- 
son why  the  same  amount  of 
new  formation  cannot  occur 
in  an  injury  to  a  bone  as  in  a 

Fig.  12. — X-Ray  of  Alveolar  Abscess     fracture  of  a  bone. 

Exostoses  are  undoubtedly  due  to  such  an  injury  to  the 
external  surface  of  a  bone  as  the  disi^lacing  or  detaching 
of  the  periosteum  and  increasing  the  piling  up  of  new  bone 
material  in  a  conical  shape. 

Figure  12  shows  an  X-ray  picture  of  a  chronic  alveolar 
abscess.  It  will  be  observed  that  the  cavity  extends  from 
the  root  of  the  central  through  the  alveolar  process  above 
the  crown.  The  root  of  the  tooth,  which  is  found  within 
the  abscess  cavity,  is  considerably  atrophied.  It  will  also 
be  observed  that  there  is  a  very  small  space  on  the  opposite 
side  of  this  tooth,  showing  that  the  entire  apex  of  the  root 
is  denuded,  extending  into  the  center  of  the  cavity.  The 
treatment  for  such  a  case  is  the  extraction  of  the  tooth, 
which  alone,  in  some  instances,  might  completely  cure  the 
disease.  It  is  better,  however,  if  a  prompt  recovery  is  de- 
sired, to  curette  away  that  part  of  the  alveolar  process 
labial  to  the  tooth  which  has  been  extracted  and  sufficient 


ALVEOLAR    ABSCESS    OF    THE    MAXILLA         119 

of  the  process  through  the  tooth  which  was  formerly  re- 
moved, to  allow  the  periosteum  to  collapse  back  into  the 
depression,  thus  obliterating  it.  Of  course,  it  is  necessary 
to  curette  the  entire  cavity  so  as  to  make  it  bleed  freely. 
No  packing  should  be  used. 

Figure  13  shows  an  alveolar  abscess  following  the  in- 
fection of  a   root  canal,  which  occurred  after  the   tooth 


Fig.  13. — Granulation  from  Abscess  Resembling  Papilloma. 

had  been  broken  off.  The  case  illustrates  the  characteristic 
granuloma  which  is  found  around  a  canal  leading  into  de- 
nuded bone.  It  might  be  mistaken  for  an  epulis,  papilloma, 
or  even  more  grave  varieties  of  tumors.  An  opening  is 
always  found  in  the  center  of  a  granuloma  which  leads  into 
dead  bone.  This  case  was  cured,  however,  without  the  loss 
of  the  tooth. 

Alveolar  Abscess  of  the  Maxilla.— Attention  must  be 
called  to  the  difference  in  the  course  of  an  abscess  from  a 
tooth  in  the  mandible  and  from  one  in  the  maxilla.    Those 


120 


ALVEOLAR  ABSCESS 


of  the  maxilla  run  a  more  satisfactory  course  naturally, 
because  the  drainage  from  the  diseased  area  is  better. 
^Yhere  the  disease  is  in  the  mandible,  there  is  no  drainage 
from  the  dependent  or  lowest  point  of  the  cavity.  Drain- 
age must  be  upward,  out  through  the  alveolar  mucous  mem- 
brane or  through  the  skin  below  the  body  of  this  bone. 

If  the  root  of  the  tooth  atfected  is  in  proximity  to  the 
maxillary  sinus,  this  cavity  will  be  affected,  resulting  in 
antral  disease.    In  many  of  these  abscesses  the  bony  floor 


Fig.  14. — The  Most  Common  Alveo- 
LAK  Fistula  of  the  Maxilla.  Usu- 
ally persists  for  years  iintil  the  tooth 
IS  extracted;  and  the  bone  on  the  buc- 
cal side  removed. 


Fig.  15. — Method  of  Establish- 
ment of  Naso-oral  Fistula,  a, 
nasal  septum;  b,  nasal  cavity;  c,  mem- 
branous floor;  d,  abscess  cavity;  e, 
denuded  root  of  tooth. 


of  the  antrum  is  destroyed,  yet  the  antral  cavity  is  not 
entered  because  the  membranous  floor  is  still  intact.  In 
alveolar  abscess  of  the  mandible  it  is  not  uncommon  for 
the  abscess  to  break  through  the  cheek.  It  is  all  a  question 
of  dependent  drainage. 

The  second  serious  consequence  of  alveolar  abscess  is 
a  more  grave  variety  of  destruction  of  the  maxillary  bone, 
when  the  nasal  floors,  membranous  and  osseous,  are  de- 
stroyed, leaving  a  naso-oral  fistula.  In  this  condition  we 
have  a  very  troublesome  complication,  making  it  necessary 
for  the  patient  to  keep  the  opening  packed  constantly,  re- 


TREATMENT 


121 


quiring  removal  of  the  packing  after  meals,  and  withal  leav- 
ing the  mouth  in  a  very  unsanitary  condition. 


Fig.  16.— Abscess,  a,  antral  cavity;  h,  naso-antral  septum;  c,  membranous 
floor  of  the  antrum;  d,  abscess  cavity  ready  to  rupture  into  the  antrum;  e, 
root  of  tooth  denuded  and  cause  of  disease. 


Fig.  17. — Alveolar  Abscess  of  the  Mandible.  A,  abscess  cavity;  B,  roots  of 
tooth;  C,  external  alveolar  plate  to  be  removed  with  tooth;  D,  point  of 
incision. 

Treatment.— Assuming  that  the  dentist  has  made  an  ef- 
fort to  close  an  alveolar  fistula  by  cutting  off  the  root 
of   the    tooth   and   by   draining    through    the    tooth,    and 


122  ALVEOLAR  ABSCESS 

that  neither  of  these  methods  has  resulted  in  a  closure, 
and  that  the  j^rocess  of  disintegration  of  the  bone  has 
extended  through  a  period  of  several  months,  the  case 
is  one  for  major  surgical  operation.  The  operative 
treatment  includes  the  removal  of  the  offending  tooth 
and  of  that  part  of  the  alveolar  process  external  to 
the  tooth  on  the  side  of  the  fistula.  If  other  teeth  have  been 
removed  on  either  side  of  the  offending  tooth  which  has 
been  extracted,  the  periosteum  should  be  carefully  dissected 
away  from  the  bone  up  to  the  fistula.  This  is  for  the  pur- 
pose of  preserving  it,  so  that,  after  all  of  the  bone  up  to 
the  fistula  has  been  removed,  it  may  be  collapsed  back 
against  the  posterior  wall  of  the  cavity  and  in  this  way 
serve  as  a  flap,  so  that  repair  may  take  place  without  fur- 
ther exfoliation. 

The  later  management  of  an  alveolar  abscess  varies 
greatly  with  the  different  operators.  It  is  the  author's 
practice  to  convert  an  alveolar  abscess  or  a  suppurative 
condition  of  the  bones,  either  acute  or  chronic,  into  a  ster- 
ile field  by  the  use  of  strong  antiseptics,  after  a  thorough 
removal  of  all  devitalized  and  infected  bone.  Then  it  is 
closed  by  either  suturing  the  gingival  mucous  membrane 
together  across  the  cavity  or  making  pressure  upon  the 
outside  between  the  cheek  and  the  bone  with  a  considerable 
piece  of  gauze,  so  that  the  cavity  may  be  obliterated  by 
the  collapsing  of  the  membranous  walls  against  the  floor. 


CHAPTER  XIV 


MOUTH  LESIONS 


Stomatitis  is  an  inflammation  of  mucous  membrane  and, 
secondarily,  of  other  structures  of  the  mouth.  The  differ- 
ent varieties  are  undoubtedly  due  to  bacterial  invasion, 
rendered  possible  by  reduced  vitality.  It  is  a  term  very 
loosely  and  generally  used  by  writers  to  include  any  variety 
of  irritation  or  inflammation  or  congestion  of  the  mucous 
membrane  and,  secondarily,  of  the  deeper  structures.  Oral 
pathologists  and  pediatrists  have  not  agreed  upon  a  uni- 
form and  systematic  classification,  the  basis  of  which  has 
been  the  remote  etiological  factors.  Many  conditions  pro- 
duce similar  lesions  in  the  mouth,  the  remote  factor  having 
passed  and  a  local  inflammation  remaining  to  be  treated. 
Again,  mouth  lesions  form  one  of  many  symptoms  of  con- 
stitutional diseases,  as  typhoid  fever,  scarlatina,  measles, 
syphilis,  etc.  We  further  observe  that  what  have  been 
classed  as  distinct  diseases  are  only  different  stages,  one 
passing  over  into  another,  i.  e.,  catarrh  may  become  ulcera- 
tive and  finally  result  in  bone  exfoliation;  herpetic  ulcera- 
tions may  coalesce  into  larger  ulcers,  resembling  the  pri- 
mary ulcerative  variety. 

To  simplify,  and  at  the  same  time  present  a  classification 
sufficiently  clear  to  answer  all  requirements  of  the  student 
of  dentistry,  the  following  is  selected.  It  is  based  upon  the 
earliest  lesion  of  the  various  diseases,  which,  as  has  been 
said,  may  become  a  second  form  as  the  disease  advances. 
The  word  aphtha  is  used  by  both  Holt  and  Smith  (pedia- 
trists) as  a  synonym  of  herpes,  but  dictionaries  say  that  it 

123 


124 


MOUTH   LESIONS 


is  a  synonym  of  thrush.  Burcliard  says:  ^'Thrush  and 
aphtha  are  different  diseases."  Holt,  in  a  personal  letter, 
says :  "It  (aphtha)  is  a  general  term,"  and  for  this  reason 
it  is  not  nsed  in  this  book  as  being  a  primary  disease. 

The  following  classification  appears  to  be  most  accepta- 
ble.   See  also  the  differential  table  later  in  the  chapter. 


Local  acute 
stomatitis . 


Symptomatic 
month   lesions. 


(a)  Catarrhal. 

(b)  Ulcerative.  . 

(c)  Herpetic. 

(d)  Mycosic. 

(e)  Gangrenous. 


1.  Canker  sores. 

2.  Alveolar  ulcerations. 


Acute 

Constitutional. . 
Diseases. 


Chronic 
J  Constitutional .  . 
Diseases 


a.  Measles. 

b.  Diphtheria. 

c.  Scarlatina. 

d.  Typhoid. 


r  a.  Tuberculosis,    f   1.  Chancre. 

1.  Patches. 

b.  Syphilis '    3.  Gumma. 

4.  Ulcerative  gin- 


Drugs  . 


a.  Mercury. 

b.  Lead. 

c.  lodids. 

d.  Piloearpin- 

e.  lodin. 


givitis. 


Mouth  lesions  associated  with  skin  diseases. 
Vincent's  angina. 


LOCAL  ACUTE  STOMATITIS 

(a)  Cataekhal  Stomatitis 

This  condition  is  an  acute  disease  beginning  in  the  mu- 
cous membrane,  characterized  by  redness,  with  injection 
and  dilatation  of  the  capillaries,  with  a  tendency  to  oozing 
and  swelling,  especially  of  the  alveolar  mucous  membrane. 
It  may  include  the  lips,  tongue  and  other  parts. 

Symptoms.— Local  elevation  of  temperature  is  marked, 
the  moutb  is  hot,  the  tongue  coated,  edges  red  and  papillae 
prominent,  with  fissures  in  the  tongue  as  a  later  manifesta- 


LOCAL   ACUTE    STOMATITIS  125 

tion.  Pain  is  quite  severe  and  tenderness  so  marked  that 
solids  and  even  hot  liquids  cause  the  patient  great  distress. 
The  normal  salivary  secretion  is  markedly  increased,  being 
so  abundant  as  to  trickle  from  the  mouth  and  soil  the  cloth- 
ing. There  is  usually  induration  of  the  neighboring  lym- 
phatic glands  during  active  symptoms.  Constitutional 
symptoms  are  mild.  The  causes  are  some  mechanical  or 
chemical  irritations  from  decayed  or  neglected  teeth. 

Treatment.— The  treatment  is  simple  and  consists  in  re- 
moval of  the  cause  and  correction  of  unhealthy  conditions 
about  the  teeth.  The  teeth  should  be  thoroughly  cleansed 
and  kept  clean.  The  use  of  boric  acid  or  other  antiseptic 
washes  is  usually  followed  by  recovery.  The  bowels  should 
be  emptied  and  nutritious  foods  given. 

(b)  Ulcerative  Stomatitis 

Two  forms  of  ulceration  may  be  considered,  the  first 
being  the  most  common. 

1.    Canker  Sores 

These  may  be  associated  with  gastrointestinal  disturb- 
ances or  they  may  follow  trauma.  They  have  also  been 
known  to  depend  upon  excessive  acid  saliva.  Cases  of 
canker  ulcers,  developing  periodically,  have  disappeared 
entirely  after  defective  teeth  have  been  filled  or  removed. 
They  appear  on  the  cheek,  tongue  or  gums  as  depressed 
ulcers,  the  base  is  dark  and  rough  and  has  a  hyperemic 
zone.  The}^  are  sensitive  at  all  times  and  painful  to  the 
touch,  especially  when  eating. 

2.    Ulcerative  Stomatitis  or  Alveolar  Ulceration 

This  is  an  ulcerative  process,  beginning  at  the  free  gum 
margin,  usually  on  the  buccal  side,  and  extending  to  other 
parts  of  the  oral  cavity.    Ulcerous  membranous  stomatitis 


126  MOUTH   LESIONS 

is  a  contagious  infectious  disease.  Although  the  investiga- 
tions of  Netter,  Bergeron  and  Fruehwald  have  not  led  to  a 
positive  result  in  regard  to  the  demonstration  of  a  specific 
cause,  the  endemic  occurrence  of  this  disease,  as  well  as 
its  rapid  spreading  under  given  circumstances,  is  unques- 
tionable. Brotonneau,  for  instance,  reports  concerning  an 
endemic  spread  of  stomatitis  ulcero-membranosa  in  the 
Army  de  la  Vendee  at  Tours  in  the  year  1828.  Moussu 
records  the  case  of  a  soldier  who  infected  himself  from  a 
pipe,  and  who  transmitted  the  disease  to  five  comrades. 
De  Sotolongo  cites  the  clinical  history  of  a  sergeant,  who, 
from  unknown  cause,  had  been  infected  with  ulcerous  mem- 
branous stomatitis,  and  within  the  first  five  or  six  days  had 
transmitted  the  disease  to  many  soldiers. 

Contributing  causes  are  scurvy,  depraved  conditions  of 
the  constitution,  such  as  may  be  found  among  the  poorer 
classes,  in  whom  no  attention  is  given  the  mouth,  and  bad 
hygienic  conditions.  No  other  bacteria  than  the  usual  pyo- 
genic variety  have  been  found.  The  appearance  is  at  first 
that  of  a  superficial  ulcer,  extending  backward  and  for- 
ward in  a  continuous  process  until  several  teeth  are  in- 
cluded, and  extending  down  over  the  bone  to  the  buccal 
membrane,  resulting  in  large  ulcers.  When  neglected  it 
may  include  the  peridental  membrane,  the  teeth  becoming 
loose.  The  periosteum  may  become  involved  and  super- 
ficial necrosis  result. 

Symptoms.— The  symptoms  are  fetid  breath  with  pro- 
fuse salivation.  The  gums  are  purple  or  red,  swollen  and 
spongy.  The  gingival  margin  of  the  ulcer  is  a  muddy 
yellow,  and  bleeds  freely  when  curetted  or  touched.  The 
ulcer  is  very  painful  and  tender.  In  scorbutic  ulcers  the 
spongy  condition  may  extend  about  the  teeth.  The  tongue 
is  swollen  extensively  and  coated  with  a  dark  fur.  The 
adjacent  lymphatics  are  enlarged.  The  constitutional  con- 
ditions, usually  bad  to  begin  with,  become  worse,  and  in 
neglected  cases  extensive  ulceration  and  even  loss  of  teeth 


LOCAL   ACUTE    STOMATITIS  127 

follow.  A  fatal  termination  is  rare,  except  that  it  so  re- 
duces the  system  that  intestinal  or  other  complications  may 
develop. 

Treatment.— The  treatment  consists  in  most  painstaking 
cleansing  of  the  mouth,  together  with  the  removal  of  all 
tartar  from  the  teethj  and  washings  with  antiseptic  solu- 
tions. Cauterization  with  iodin,  silver  nitrate,  etc.,  is  use- 
less. In  such  cases  pure  hydrochloric  acid  has  proved  to  be 
an  excellent,  always  effective,  almost  specific,  therapeutic 
agent.  The  plaques  and  gingival  borders  are  touched  there- 
with, and  rinsings  with  boric  acid  mixed  with  phenol  are 
prescribed  after  the  following  formula :  Three  per  cent, 
boric  acid,  950  grams;  glycerin,  50  grams;  phenol,  0.05 
gram. 

Before  cauterizing,  the  anesthetizing  of  the  mucosa 
with  a  two  per  cent,  cocain  solution  is  recommended.  The 
expeditious  effect  of  hydrochloric  acid  is  attributed  directly 
to  the  destruction  of  the  bacteria.  Holt  says  that  potas- 
sium chlorate,  in  two-grain  doses,  largely  diluted,  given 
every  'hour  for  twenty-four  hours,  to  be  reduced  one-half 
the  second  day,  is  a  specific.  When  decayed  or  loose  teeth 
or  concealed  roots  are  present,  they  should  be  removed  or 
treated.  Exfoliations  should  be  removed.  Under  proper 
and  vigorous  treatment  repair  should  follow  in  a  week  or 
two,  but  when  hygienic  conditions  cannot  be  corrected,  the 
ulceration  may  last  for  several  weeks.  In  scorbutic  cases, 
special  diet,  such  as  orange  and  beef  juice,  with  a  proper 
artificial  food,  such  as  malted  milk,  should  be  given. 

Illustrative  Case.— A  boy,  aged  twelve,  had  had  pneu- 
monia, from  which  he  made  a  fair  recovery.  In  about  two 
weeks  ulceration  of  the  gingival  mucous  membrane  was 
observed.  This  continued  until  all  of  his  teeth  below  were 
loose,  the  floor  of  the  mouth  necrotic,  temperature  high 
and  fetor  marked.  He  died  in  two  weeks  from  onset.  See 
figure  18. 


128  MOUTH   LESIONS 

(c)   Heepetic   Stomatitis 

Herpes  of  the  moutli,  sometimes  called  follicular  stoma- 
titis, is  an  inflammation  of  the  follicles  of  the  mucous  mem- 
brane. 

Symptoms.— The  appearance  is  of  small,  yellowish- 
white  spots,  one-eighth  of  an  inch  in  diameter,  which  break 
down  into  superficial  ulcers.     Two  or  more  may  coalesce. 


Fig.  18. — Ulcerative  Stomatitis. 

forming  large  ulcers.  The  ulcers  are  shallow,  healing  in 
the  course  of  a  few  days,  to  be  followed  by  another  crop. 
They  are  located  along  the  margin  of  the  tongue  and  on 
the  internal  surface  of  the  lips.  The  cause  is  supposed  to 
be  nervous,  or  a  primary  lesion  in  the  nervous  system, 
resembling  herpes  circinatum  (shingles)  and  herpes  fronta- 
lis. 

The  local  lesions  are  attributed  to  trophic  changes,  due 
to  a  neuritis  of  the  nerve  supplying  the  involved  parts.  The 
only  two  diseases  of  the  mouth  for  which  herpetic  stomati- 


LOCAL   ACUTE    STOI\IATITIS  129 

tis  may  be  mistaken  (and  then  only  in  the  early  stage;  for 
later,  when  eruption  is  complete,  no  confusion  is  possible) 
are  ulcerative  stomatitis  and  aphthous  stomatitis. 

Treatment.— The  treatment  is  the  same  as  that  outlined 
for  the  catarrhal  form,  with  the  addition  of  alum  or  other 
caustic  applied  directly  to  the  ulcer.  Tonics  containing 
iron  and  strychnia  may  be  given  internally.  Repair  fol- 
lows in  a  week  or  ten  days. 

(d)  Mycosic  Stomatitis  (Aphthous) 

Thrush  is  a  fungoid  disease  of  the  mucous  membrane 
of  the  mouth.  The  saccharomyces  albicans  is  the  variety 
of  fungus  producing  the  trouble.  The  lesion  is  caused  by 
spores  forcing  their  way  between  the  different  layers  of 
epithelial  cells  and  gradually  extending  to  the  surrounding 
cells.  It  begins  by  the  formation  of  many  small  spots, 
which  spread  until  they  are  united,  and  a  patch  of  one- 
fourth  to  one-half  of  an  inch  or  larger  in  diameter  is 
formed.  The  borders  are  irregular  and  the  patches  are 
slightly  elevated  above  the  healthy  membrane.  They  look 
like  flakes  of  coagulated  milk,  but,  while  the  latter  can  eas- 
ily be  removed,  the  former  are  intimately  adherent.  They 
are  usually  located  upon  the  tongue,  inside  of  the  cheek, 
pillars  of  fauces,  tonsils  and  pharynx,  although  no  part  of 
the  oral  cavity  is  exempt. 

Symptoms.— The  mouth  is  usually  dry,  painful  and  ten- 
der, the  tongue  is  coated,  and  there  is  difficulty  in  swallow- 
ing. Glandular  enlargements  are  rare.  It  is  differentiated 
from  the  other  varieties  of  stomatitis  by  the  absence  of 
ulceration  or  pus  formation,  but  there  is  instead  an  irregu- 
lar elevated  patch,  which  is  at  first  pearly  white,  but,  as 
time  approaches  for  it  to  shed,  becomes  yellow.  Diph- 
theritic patches  most  resemble  thrush,  but  in  diphtheria 
the  patches  usually  begin  on  the  tonsils  or  in  the  pharynx, 
the  deposit  is  thicker,  more  defined  and  continuous,  and 
there  is  glandular  infiltration  with  marked  constitutional 


130 


MOUTH   LESIONS 


symptoms.  Recovery  usually  follows,  though  in  feeble 
children  the  condition  may  persist  and  death  may  result 
from  inanition. 

Treatment.— The  treatment  should  begin  with  correction 
of  the  diet  and  methods  of  administration  of  food.     The 


Fig.  19. — Mycosic  Stomatitis. 

mouth  should  be  cleansed  and,  in  artificially  fed  children, 
the  bottle,  nipple,  etc.,  should  be  kept  sterile,  while  the 
food  products  should  be  of  the  best.  Antiseptics,  such 
as  borax  and  bicarbonate  of  soda,  in  a  powder,  should 
be  applied  locally.  Honey  and  sugar  should  not  be 
used,  as  they  encourage  fermentation.  AgNOg  applied 
to  ulcers  and  keeping  the  mouth  clean  are  the  most 
satisfactory  treatments.  One  application  is  usually  all 
that  is  necessary. 


LOCAL   ACUTE    STOMATITIS  131 

(e)   Canceum  Oris 

Gangrenous  stomatitis,  also  known  as  noma  and  can- 
crum  oris,  is  a  destructive  inflammation  of  the  mucous 
membrane  and  other  structures  of  the  mouth.  It  is  gener- 
ally a  sequela  of  measles,  but  may  follow  any  of  the  eruptive 
fevers.  A  predisposing  cause  is  the  low  vitality  of  the 
child  from  the  former  disease.  A  specific  microbe  or  para- 
site has  not  been  found,  although  streptococci  are  usually 
present  in  cultures  made  from  the  product. 

Symptoms.— It  begins  with  marked  constitutional  symp- 
toms. The  temperature  is  high,  the  pulse  rapid,  the  mus- 
cles relaxed,  and  grave  conditions  develop  in  four  or  five 
days.  Fetid  breath  is  very  early  observed.  Locally  there 
is  discoloration  or  a  mottled  condition  of  the  mucous  mem- 
brane over  the  alveolus  or  on  the  buccal  surface  of  the 
cheek.  The  tissues  are  swollen  and  doughy,  with  marginal 
infiltration.  The  skin  over  the  cheek  is  swollen  and  glossy. 
At  first  red,  it  soon  becomes  purple  and  then  black.  The 
epidermis  loosens  and  is  cast  off  during  the  first  few  days. 
The  teeth  become  loose,  necrosis  of  the  process  soon  fol- 
lows, or,  when  the  disease  is  confined  to  the  cheek,  the  line 
of  demarcation  is  soon  established  and  the  necrotic  slough 
comes  away  in  the  course  of  a  week,  leaving  a  perforation 
from  skin  to  mucous  membrane.  Pain  is  not  severe.  The 
entire  cheek  or  the  entire  mandible  or  maxilla  may  be  de- 
stroyed by  the  disease. 

The  accompanying  illustration  is  that  of  a  child  aged 
five  years,  who  had  typhoid  fever  beginning  June  8.  On 
June  22,  when  fever  had  about  run  its  course,  the  attend- 
ing physician  noticed  a  swelling  of  the  left  cheek.  On 
June  24  the  skin  over  the  cheek  became  glossy.  On  June 
26  the  physician  decided  that  an  abscess  had  formed  and 
made  an  incision  through  the  mucous  membrane  over  the 
maxilla  of  the  superior  sulcus  of  the  mouth,  and,  to  his 
great  surprise,  the  knife  passed  directly  into  the  bone, 
which  was  denuded.     With  a  probe  he  found  that  almost 


'132 


MOUTH    LESIOXS- 


the  entire  external  surface  of  this  bone  was  denuded  of 
periosteum.  June  30,  the  epidermis  of  the  cheek,  about 
one  and  one-half  by  two  and  one-half  inches,  came  off,  leav- 
ing a  glossy  discolored  derma  vera,  which  was  evidence  to 
him  that  gangrene  had  begun.  At  this  time  a  diagnosis  of 
cancrum  oris  was  made  and  the  patient  removed  to  the 
hospital  July  1.     The  history  of  the  case  from  this  time 


Fig.  20. — Cancrum  Oris. 

on  was  that  of  progression,  the  gangrene  rapidly  extending 
into  new  iields  in  every  direction,  so  that  at  the  time  of 
death,  July  10,  the  outer  angle  of  the  mouth  and  the  left 
anterior  naris  were  included;  the  entire  maxilla  was  de- 
stroyed, since  the  entire  surface  was  bare  as  well  as  the 
roof  of  the  mouth  on  the  left  side. 

Prognosis.  — The  prognosis  is  grave,  and  it  is  only  when 
the  disease  is  limited  within  itself  that  recovery  takes  place. 
Three-fourths  of  the  cases  terminate  fatally  in  from  four 


SYAIPTOMATIC    MOUTH    LESIONS  133 

to  six  days.  When  the  line  of  demarcation  is  early  estab- 
lished the  slough  comes  away,  repair  is  very  slow,  requiring 
many  weeks  for  granulation  and  cicatrization,  and  an  ob- 
jectionable cicatrix  or  perforation  or  other  deformity  is 
the  legacy. 

Treatment.— The  treatment  consists  in  cleanliness,  at- 
tention to  diet,  stimulation  and  nutrition.  The  slough 
should  be  removed  early,  under  an  anesthetic  if  necessary, 
and  the  margin  of  the  ulcer  cauterized  by  the  actual  cautery 
or  by  lunar  caustic.  Vigorous  and  jorompt  measures  are 
demanded  if  recovery  is  to  be  expected. 

SYMPTOMATIC  MOUTH  LESIONS 

Symptomatic  lesions  of  the  mouth  are  found  when  some 
general  or  constitutional  disease  exists,  and,  along  with 
other  well-defined  symptoms,  there  is  also  present  a  lesion 
in  the  mouth,  always  secondary  and  of  minor  importance. 
They  are  included  here  to  make  a  more  complete  differential 
table  and  to  acquaint  the  dentist  with  all  lesions  of  the 
mouth. 

Measles  has  no  mouth  lesion  except  the  earliest  mani- 
festation of  the  eruptive  stage,  which  is  observed  in  the 
roof  of  the  mouth  in  the  form  of  dark  red  or  brown  irregu- 
lar or  mottled  spots.  About  the  same  time  similar  spots 
may  be  observed  back  of  the  ears  and  neck. 

Diphtheritic  lesions  first  appear  in  the  pharynx  and 
tonsils  and  only  appear  in  the  mouth  by  extension.  They 
can  readily  be  differentiated  from  thrush  on  account  of  the 
marked  constitutional  symptoms. 

Scarlatinal  lesions  of  the  mouth  appear  in  the  form  of 
membranous  deposits  termed  erythema,  or  pseudo-diph- 
theria. Here  are  found  marked  constitutional  symptoms 
and  the  skin  eruption  so  characteristic  of  the  disease. 

Typhoid  fever  is  a  frequent  forerunner  of  gangrenous 
stomatitis.  The  case  reported  in  this  chapter  followed  that 
disease. 


134  MOUTH   LESIONS 

Tuberculous  and  syphilitic  mouth  lesions  are  fully  con- 
sidered in  the  chapters  treating  of  these  diseases. 

Mercury  Poisoning 

Mercurial  stomatitis  is  an  inflammation  of  the  mouth 
and  salivary  glands  caused  by  the  excessive  use  of  mercury. 
A  similar  condition  is  rarely  seen  as  a  result  of  the  thera- 
peutic use  of  other  drugs.  This  is  seen  in  barometer- 
makers,  mirror  silverers,  chemists  and  others  who  handle 
mercury  in  their  daily  work.  The  exciting  cause  of  ptyal- 
ism  is  the  ingestion,  inhalation  or  cutaneous  absorption  of 
mercury. 

Symptoms.— A  metallic  taste  in  the  mouth  is  first  no- 
ticed by  the  patient.  Soon  the  gums  become  red,  swollen, 
tender  to  the  touch,  and  sore  during  the  act  of  mastication. 
A  marked  secretion  and  flow  of  saliva,  with  a  fetid  breath 
and  swollen  tongiie,  follow.  Very  rarely  in  this  disease  the 
infection  passes  into  an  ulcerative  stomatitis  and  causes 
loosening  of  the  teeth  and  necrosis  of  the  maxilla. 

Chronic  Lead  Poisoning 

The  characteristic  blue  line  at  the  borders  of  the  gums 
is  rarely  absent,  especially  in  those  who  are  not  scrupulous 
in  their  attention  to  the  teeth.  It  is,  as  a  rule,  most  dis- 
tinct at  the  roots  of  the  lower  cuspids  and  incisors,  and 
is  formed  by  a  deposition  of  lead  sulphite.  Bluish  patches 
may  also  be  met  with.  Gowers  points  out  that  this  line  is 
black  instead  of  blue  and  is  present  only  when  the  gums 
are  slightly  separated  from  the  teeth. 

PiLOCARPIN 

Pilocarpin  may  cause   swelling   of  the   salivary  glands 
and  tonsils. 


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136  MOUTH   LESIONS 

lODIN 

Under  the  name  of  iodism,  the  profession  recognizes  a 
state  of  the  body  brought  about  by  the  prolonged  and 
excessive  use  of  iodin  in  any  of  its  forms.  The  earliest 
notable  signs  of  this  state  are  a  peculiar  metallic  taste  in 
the  mouth,  particularly  in  the  morning,  slight  tenderness  of 
the  teeth  and  gums,  increase  of  salivary  secretion,  morn- 
ing nausea  and  a  lack  of  appetite  for  breakfast,  and  per- 
haps some  coryza  or  evidence  of  gastric  irritation. 

SOME  AFFECTIONS  OF  THE  NASAL  AND  ORAL  CAVITIES 
WHICH  ARE  RELATED  TO  SKIN  DISEASES 

Among  specialists,  the  consideration  of  mucous  mem- 
brane affections  as  related  to  skin  diseases  is  chiefly  one 
of  diagnosis.  The  correlation  of  the  two  structures  is 
recognized  not  only  in  purely  dermatological  cases,  where, 
in  obscure  diseases,  we  usually  rely  upon  mucous  lesions 
to  establish  a  diagnosis,  but  also  in  general  conditions,  such 
as  the  acute  exanthemata,  where  much  importance  is  at- 
tached to  the  primary  Koplik  spots  on  the  buccal  and  labial 
mucosae  in  measles,  the  vesicles  and  pustules  in  the  mouth 
and  pharynx  of  smallpox  and  varicella  patients,  and  some 
to  the  strawberry  tongue  and  pharyngitis  in  scarlet  fever. 
On  the  mucous  membranes,  however,  lesions  present  pecu- 
liarities which  are  not  seen  on  the  skin,  making  the  question 
of  diagnosis  more  complicated. 

The  most  important  disease  of  the  skin,  eczema,  has  its 
counterpart  in  catarrh  of  the  mucous  membrane.  The  path- 
ological process  is  the  same  in  both,  namely  hyperemia, 
swelling,  exudation,  and  epithelial  desquamation.  Etio- 
logically  there  is  a  further  relationship  in  that  local  irri- 
tants or  some  remote  factor^  such  as  inherent  vulnerability, 
may  be  operative  in  both  conditions,  while,  among  the  sub- 
jective symptoms,  an  analogue  has  been  drawn  between  the 
pruritus  of  the  skin  and  the  coughing  and  sneezing  follow- 


AFFECTIONS    RELATED    TO    SKIN    DISEASES     137 


Fig.  21.— Strawberry  Tongue.  Fig.  22.— Follicular  Tonsilitis. 


Fig.  2.3. — Diphtheritic  Throat.  Fig.  24. — Koplik's  Spots. 

(Palisade  Mfg.  Co.) 


138  MOUTH   LESIONS 

ing  catarrhs  of  the  respiratory  tract.  Catarrhal  inflamma- 
tions of  the  skin  may  alternate  with  those  of  the  mucous 
membranes,  the  one  being  active  while  the  other  is  held  in 
abeyance.  This  view  is  upheld  by  Broca,  and  it  may  be 
due  to  the  same  pathological  law  which  governs  the  sub- 
sidence of  an  inflammation  in  one  organ  while  it  is  active 
in  another.  The  absence  of  febrile  disturbances  in  cutane- 
ous catarrhs  has  been  accounted  for  by  the  heat  radiation 
from  the  surface  and  the  elimination  of  toxic  products 
through  the  excretions. 

A  catarrhal  condition  of  the  skin  is  often  set  up  by  one 
of  the  mucous  membranes  and,  conversely,  the  mucous 
membranes  may  be  involved  by  autoinoculation  from  the 
skin.  This  is  frequently  illustrated  by  an  eczematoid  der- 
matitis of  the  contiguous  skin  resulting  from  discharges 
from  the  eye,  ear,  nose,  mouth  or  genitals.  The  lesion,  usu- 
ally staphylogenic  in  origin  and  vesicular  or  erythematous, 
soon  forms  eczematous  plaques,  which  by  confluence  or  pro- 
gression involve  large  areas,  or  by  autoinoculation  produce 
new  ones. 

Eczema  of  the  cheeks  in  children  can  often  be  traced 
to  sleeping  with  the  mouth  open  and  the  dribbling  saliva 
in  subjects  of  adenoids.  The  connection  between  the  mu- 
cosa and  integument  is  further  demonstrable  in  cases  of 
refractory  sycosis  of  the  lip  produced  by  pus  organisms 
in  an  irritating  nasal  discharge  and  in  facial  erysipelas  or 
the  recurring  erysipelatoid  flush  of  the  face  from  picking 
the  nose. 

Impetigo  contagiosa  also  attacks  the  mucous  membranes 
of  the  nose  and  mouth,  and  may  precede,  accompany  or  fol- 
low the  skin  eruption.  It  is  usually  seen  as  isolated  vesicles 
or  pustules  which  become  encrusted.  More  rarely  a  papil- 
lomatous condition  develops.  The  impetigo  of  Bockhart  re- 
sults from  autoinoculation  with  the  staphylococcus,  and  is 
produced  by  scratching  in  pruritic  diseases.  The  lips  and 
mouth  are  eroded  and  the  lesions  may  by  confluence  give 


AFFECTIONS    BELATED    TO    SKIX    DISEASES      139 

rise  to  phlegmonous  areas.  In  a  ease  of  fulminating 
ecthyma  the  lesion  began  on  the  hand  and  by  autoinfeetion 
involved  the  head,  face,  thighs,  mucous  surface  of  the  lips, 
and  soft  palate  and  nose,  where  numerous  pea-sized  super- 
ficial erosions  were  present,  accompanied  by  a  fetid  sero- 
purulent  nasal  discharge.  Marked  septic  symptoms  were 
present,  and  the  case  had  a  fatal  issue.  At  autopsy  the 
entire  larynx  and  the  trachea  were  also  found  ulcerated. 
The  bacteriological  examination  showed  staphylococci, 
streptococci,  and  a  slender  unclassified  bacillus. 

All  the  types  of  pemphigus  attack  the -mucous  mem- 
branes, that  of  the  mouth  most  frequently.  They  may  be 
involved  early  or  late  in  the  course  of  the  disease,  often 
preceding  the  skin  eruption  by  months,  so  that  early  diag- 
nosis may  rest  with  the  nose  and  throat  specialist  rather 
than  with  the  dentist  or  an  oral  surgeon.  Early  manifesta- 
tions in  the  mouth  and  in  the  larynx  are  not  uncommon, 
however,  and  the  j^resence  of  bullae  and  erosions  in  the  oral 
cavity,  accompanied  by  constitutional  disturbance  and  loss 
of  weight,  are  frecj[uent  symptoms.  The  onset  is  gradual, 
requiring  several  months  for  development.  Differentiation 
must  be  made  from  simple  bullous  lesions,  and  from  inter- 
mittent mouth  infections  which  come  and  go  without  con- 
stitutional disturbance.  They  are  usually  associated  with 
bullous  dermatitis.  This  disease  may  begin  on  the  tongue 
or  any  part  of  the  mouth  or  throat,  as  well  as  the  vermilion 
border  of  the  lips. 

Herpes  zoster  may  be  understood  if  the  reader  refers 
to  this  subject  earlier  in  the  chapter,  where  it  has  been  duly 
considered. 

In  the  erythema  group,  as  well  as  in  urticaria,  angio- 
neurotic edema  and  some  forms  of  purpura,  the  mucous 
membranes  of  the  mouth,  nose,  and  respiratory  tract  may 
show  lesions.  These  conditions  cause  constitutional  symp- 
toms to  some  extent.  There  is  a  resemblance  between  ery- 
thema and  x^urpuric  conditions.     In  the  latter  condition, 


140  MOUTH   LESIONS 

there  is  usually  hemorrhage,  which,  as  a  rule,  comes  od 
very  suddenly.  This  is  typically  illustrated  in  Henoch's 
purpura.  There  is  also  a  close  resemblance  between  pur- 
pura and  erythema  multiforme.  Erythema  of  the  mouth 
must  be  differentiated  from  contagious  exanthemata, 
and  a  thorough  inspection  of  the  entire  body  should 
be  made. 

Perleche  is  a  parasitic  disease  of  the  lips,  occurring 
most  frequently  in  children  and  in  old  i^eople  in  institu- 
tions and  asylums.  It  affects  the  commissures  with  Assur- 
ing and  a  tendency  to  bleeding,  and  resembles  mucous 
patches. 

Psoriasis  of  a  true  nature  is  so  rarely  found  that  it 
need  not  be  described  here.    It  resembles  leucoplakia. 

Seborrheic  dermatitis  of  the  scalp  and  face,  sometimes 
associated  with  lesions  of  the  mucous  membrane  of  the 
mouth  and  scalp,  should  be  thoroughly  examined  to  ditfer- 
entiate  it  from  other  lesions. 

Lichenization  is  a  chronic  skin  affection,  associated  with 
itching  and  thickening  from  intoxication  and  the  ensuing 
pruritic  diseases.  It  may  be  associated  with  leucokeratosis 
of  the  mouth  and  must  be  differentiated  from  the  latter, 
which  is  due  to  tobacco  and  syphilis. 

Leprosy  results  in  mouth  lesions,  and  frequently  this 
disease  is  first  manifested  here  or  in  the  nose,  resembling 
a  coryza  from  potassium  iodid. 

Rhino  scleroma  generally  begins  in  the  mucous  mem- 
brane in  the  anterior  nares,  extending  from  the  pharynx 
into  the  mouth. 

Lupus  erythematosis  begins  with  lesions  of  the  mouth 
and  pharynx  and  is  associated  with  cutaneous  eruptions. 
Plaques  on  the  tongue  resembling  leucoplakia  and  syphilitic 
scars  are  found.  The  lips  are  swollen,  purplish  red,  and 
eroded,  and  later  become  dry  and  scaly. 

Pigmentation  of  the  mucosa  of  the  mouth  is  found  with 
Addison's   disease,  vagabond's  disease,   Darier's   disease, 


VINCENT'S    ANGINA  141 

diabetic  melanoderma,  and  acarus  infection,  and  may  be 
associated  with  the  use  of  arsenic  or  silver  nitrate. 

Mouth  lesions  also  result  from  ringworm  and  epitheli- 
oma ;  and  many  of  the  skin  lesions,  well  known  to  the  der- 
matologist and  not  above  enumerated,  have  mouth  lesions. 
In  any  case  where  a  mouth  lesion  is  associated  with  a  skin 
lesion,  a  dermatologist  should  be  consulted  with  a  view  to 
clearing  up  the  probability  of  association. 

VINCENT'S  ANGINA 

Synonyms.— Diphtheroid  angina;  ulcero-membranous 
tonsilitis ;  ulcerating  lacunar  tonsilitis ;  chancrif orm  tonsili- 
tis. 

Definition.— An  acute  infection  of  the  mouth. 

Etiology.— It  is  generally  regarded  as  due  to  the  symbi- 
otic action  of  the  bacillus  fusiform  and  a  spirillum  (Spiro- 
chaeta  denticola). 

History.— Vincent's  first  description  of  this  disease  ap- 
peared in  the  Archives  of  Laryngology,  in  1896.  In  1903 
Emil  Mayer's  paper  was  published  in  the  American  Jour- 
nal of  Medical  Science  for  February.  W.  H.  Bruce  also 
published  a  paper  in  the  London  Lancet  for  July  16,  1904. 
The  standard  textbooks  of  this  country,  so  far  as  the 
author  is  able  to  find,  furnish  but  two  brief  descrijotions : 
on  page  249  of  "Syphilis"  by  Keyes,  this  disease  is  con- 
sidered under  the  head  of  chancre;  and  in  "American  Prac- 
tice of  Surgery,"  Volume  V,  page  822,  is  found  a  very  sat- 
isfactory description.  In  Thomson's  "Diseases  of  the 
Nose  and  Throat,"  Cassell  &  Co.,  Limited,  London  (Apple- 
ton,  U.  S.),  is  found  the  best  description.  The  following  is 
quoted  from  the  latter : 

Bacteriology.— "The  bacillus  of  Vincent  is  fusiform, 
pointed  at  the  ends,  and  somewhat  bulging  in  the  middle. 
It  is  distinguished  from  the  Klebs-Loffler  bacillus  by  being 
broader  and  longer;  its  length  is  6  to  12  micromillometres. 


142  MOUTH   LESIONS 

The  bacilli  are  frequently  arranged  in  pairs,  or  in  radiat- 
ing bundles.  They  form  vacuoles,  do  not  stain  with  Wei- 
gert  or  Gram,  but  take  up  the  ordinary  basic  stains,  such 
as  fuchsin  or  methylene  blue.  The  bacillus  has  very  free 
movement.  It  can  be  cultivated  on  the  ordinary  media,  to 
which  human  blood  serum  or  ascitic  or  hydrocele  fluid  has 
been  added  (Hewlett). 

"The  spirillum  (Spirochaeta  denticola)  is  thin  and  long, 
does  not  stain  by  Gram,  and  does  not  take  up  fuchsin  so 
readily  as  the  bacillus,  has  free  movements  but  no  flagellae. 
Cover-glass  preparations  should  be  spread  and  stained 
while  fresh.  It  has  only  been  grown  in  pure  culture  under 
anaerobic  conditions. 

"Some  observers  point  out  that  fusiform  bacilli  and 
spirilla  can  be  found  in  any  ulcerating  affection  of  the 
mouth  (syphilis,  luxms,  malignant  disease,  and  gingivitis), 
and  that,  although  they  are  constantly  present  and  remark- 
ably predominant  in  cases  of  Vincent's  angina,  it  is  at 
present  sufficient  to  allow  that  the  resistance  in  such  cases 
is  singularly  modified  in  favor  of  these  bacilli  and  spiro- 
chetes, and  that  the  infectivity  of  the  disorder  has  not  been 
proved  (M.  Letulle). 

"This  form  of  ulcerating  tonsilitis  is  an  uncommon  dis- 
ease and  is  most  frequently  met  with  in  debilitated  sub- 
jects who  are  overworked  or  in  unsanitary  surroundings. 
It  occurs  chiefly  in  children,  but  is  not  uncommon  in  hospital 
residents.    It  is  but  feebly  contagious. 

Symptoms.— "The  incubation  period  is  said  to  be  six 
or  seven  days.  The  onset  of  the  disease  is  insidious,  and 
the  throat  may  be  so  little  complained  of  that  attention  is 
directed  to  it  by  the  accompanying  glandular  enlargement. 
The  disease  is  ushered  in  with  headache,  malaise,  coated 
tongue,  anorexia,  and  pains  in  the  back.  The  temperature 
rarely  exceeds  101°  F.,  and  may  remain  normal  throughout 
the  case.  The  glands  at  the  angle  of  the  jaw  are  enlarged 
and  tender  on  the  affected  side.    Discomfort  in  the  throat, 


VINCENT'S   ANGINA 


143 


fetid  breath,  and  slight  dysphagia  may  be  complained  of, 
but  the  constitutional  symptoms  are  not,  as  a  rule,  severe. 
The  fetor  is  generally  jDresent  and  is  characteristic. 

Clinical  Features.— "The  local  features  are  fairly  typ- 
ical On  the  first  day  one  tonsil  shows  an  easily  detachable 
exudation;  on  the  second  day  this  membrane  is  found  to 
rest  on  an  ulcerated  surface; 
and  on  the  third  and  fourth 
days  it  becomes  thicker  and 
softer.  The  membrane  may 
become  detached  at  its  edges, 
and  expelled  or  swallowed, 
leaving  a  slightly  ulcerated 
surface,  on  which  new  mem- 
brane forms.  The  so-called 
membrane  is,  correctly  speak- 
ing, simply  formed  by  the  ne- 
crotic tissue  from  the  surface 
of  the  ulcer.  It  is  soft,  gray, 
yellowish-gray,  or  greenish  in 
color.    T\Tien  pinched  up  with  ^''W 

forceps  it  comes  away  in  soft, 

easily  torn  fragments,  leaving  Fig.  25.— Vincent's  Angina.     ("Dis- 
p        .  T     T  easesoftheNoseandTnroat,    Dr.  St. 

an  aniractuous,  eroded  area  Clair  Thomson,  CasseU  and  Corn- 
dotted  with  small  bleeding  pa^y,  Limited.) 
points.  The  ulcer  has  an  irregular,  indolent,  flattened  base, 
the  edges  of  which  are  abrupt  or  sloping.  .  .  .  The  sur- 
rounding tissue  may  be  reddened  and  edematous.  After 
four  to  ten  days  the  pseudo-membrane  ceases  to  re-form, 
and  the  ulcerated  surface  soon  gets  clean  and  heals  over. 
But  in  more  pronounced  cases  the  tissues  are  involved  more 
deeply  and-  the  process  extends  over  the  whole  tonsil,  the 
adjoining  faucial  pillars,  the  gums,  and,  rarely,  the  side  of 
the  pharynx.  The  destruction  of  the  tissue  occurs  three  to 
four  days  after  the  onset  of  the  disease.  The  surface  in- 
volved may  separate,  leaving  a  deej^  excavation  which  heals 


.'V 


144  MOUTH   LESIONS 

up  with  slight  cicatricial  contraction.    In  the  great  majority 
of  cases  Vincent's  angina  is  a  unilateral  affection." 

Diagnosis. — Different  writers  on  this  subject  have  en- 
tirely different  opinions  as  to  what  variety  of  syphilis  is 
most  nearly  akin  to  this  disease.  Keyes  considers  it  under 
the  head  of  chancre  and  says  it  must  be  differentiated  from 
this  lesion,  and  does  not  at  all  refer  to  it  as  resembling 
either  secondary  or  tertiary  lesions.  Thomson  in  his  book 
states  that  it  can  be  confused  with  tertiary  syphilis.  It  is 
the  author's  opinion,  after  having  seen  several  cases,  that 
the  disease  is  more  likely  to  be  confused  with  the  mucous 
patches  of  secondary  syphilis  than  with  the  chancre  or 
tertiary  lesion.  It  is  difficult  to  differentiate  it  from  any 
stage  of  syphilis,  since  the  fusiform  bacillus  and  the  spiril- 
lum are  found  in  both  diseases,  and  a  diagnosis  is  only  pos- 
sible after  taking  into  consideration  the  preceding  and  suc- 
ceeding history.  In  a  recent  case,  where  there  were  prac- 
tically no  constitutional  symptoms  except  a  slight  tempera- 
ture and  rigor  for  the  first  few  hours,  there  were  two 
patches  over  the  soft  palate  just  internal  to  the  pillars  of 
the  fauces,  about  one  inch  long  and  one-half  inch  wide. 
These  patches  looked  quite  uniform  in  margin  and  ap- 
peared to  be  very  much  alike.  Specific  patches  were  sus- 
pected, but  after  nitrate  of  silver  had  been  applied  to  the 
ulcerations  for  a  few  days  they  repaired  without  scars  and 
the  patient  was  entirely  well  in  ten  days.  Keyes  reports 
one  case  of  Vincent's  angina  of  the  tip  of  the  tongue  which 
had  persisted  for  three  months,  and  another  case  which 
ran  its  course  in  a  few  weeks.  He  also  reports  a  case  in 
which  a  man  had  an  ulceration  on  the  left  tonsil,  covered 
with  false  membrane,  and  his  wife  showed  a  similar  lesion 
on  the  right  side  of  the  mouth  at  the  angle  of  the  jaw.  In 
both  of  these  cases  a  diagnosis  of  syphilis  was  made,  but 
the  ulcerations  repaired  in  a  few  weeks  without  the  develop- 
ment of  syphilitic  symptoms.  The  following  is  quoted  from 
Keyes  :...'*  the  differentiating  points,  which  are :     1. 


VINCENT'S    ANGINA  145 

The  tenderness  is  much  more  marked  in  Vincent's  angina 
than  in  chancre.  2.  The  anginous  sore  (unless  cauterized) 
is  more  superficial  than  chancre,  and  is  likely  to  be  sur- 
rounded by  more  or  less  general  inflammation.  3.  The 
glands  may  be  large  and  tender  in  either  case.  4.  Chancre 
gets  well  spontaneously;  the  angina  may  or  may  not. 
5.  Microscopic  examination  of  a  smear  establishes  the 
diagnosis." 

Prognosis.— It  is  rare  for  the  disease  to  extend  back  of 
the  tonsils  into  the  larynx  or  into  the  trachea,  but  it  is  quite 
common  to  find  it  both  in  the  hard  palate  and  in  the  mucous 
membrane  of  the  cheek,  or  about  the  teeth,  resembling 
stomatitis.  Bruce  has  reported  one  fatal  case,  but,  as  a 
rule,  the  disease  runs  a  very  mild  and  harmless  course. 
Complications  including  the  viscera  are  unknown. 

Treatment. — Pure  tincture  of  iodin,  Lugol's  solution  of 
iodin,  and  nitrate  of  silver  in  various  strengths  have  been 
used  in  the  treatment  of  this  disease.  It  is  certain  that 
whatever  application  is  made  should  be  strong  enough  to 
destroy  the  germs,  but  that  this  should  be  discontinued 
after  two  or  three  applications,  since  if  continued  it  might 
prevent  repair  of  the  ulcerations.  A  mild  antiseptic  mouth 
wash  should  be  used  at  all  times. 


CHAPTEE  XV 


DISEASES    OF    THE    TONGUE 


The  dentist,  who  has  the  tongue  as  a  background  to  his 
field  of  operation  at  all  times,  should  not  only  be  prepared 
to  recognize  a  normal  organ,  but  should  also  be  able  at  a 
glance  to  make  an  approximate  estimate  as  to  which  of  the 
various  diseased  conditions  that  are  liable  to  affect  it  are 
present. 

A  furred  tongue  occurs  in  nearly  all  fevers.  If  it  is  a 
heavy  fur,  there  is  systemic  disturbance,  usually  serious. 
If  a  light,  moist  fur,  simple  indigestion  is  present.  Uni- 
lateral furring  may  result  from  disturbed  innervation,  as 
in  conditions  affecting  the  second  and  third  branches  of  the 
fifth  nerve.  It  has  been  noted  in  neuralgia  of  these 
branches.  Light  yellow  fur  indicates  liver  derangement. 
Brown  fur  denotes  neurasthenia,  also  intestinal  putrefac- 
tion, and  is  a  bad  indication,  especially  if  of  a  very  dark 
color.  If  this  is  combined  with  dryness  and  fissures,  the 
condition  is  very  grave. 

A  beefy  tongue  occurs  in  chronic  inflammations  of  the 
bowels,  liver  or  mucous  surfaces,  but  if  the  tongue  is  flabby 
and  gray-coated  with  an  oval  bare  spot  in  the  center  which 
is  red  and  glossy,  as  is  sometimes  seen  in  children,  it  is 
indicative  of  gastrointestinal  catarrh. 

A  black  coating  on  the  tongue  is  found  in  dysentery,  and 
indicates  collapse  and  impending  death,  and  in  jaundice, 
when  it  denotes  organic  disease  of  the  liver.  It  is  also 
an  unfavorable  sign  in  smallpox.  A  bluish  tongue  denotes 
impeded  circulation  and  interference  with  respiration.  It 
is  indicative  of  heart  disease  and  asthma.     Redness  along 

146 


CONGENITAL  DEFECTS  147 

the  center  of  the  tongue  means  intestinal  irritation  and  is 
an  early  sign  in  typhoid  fever.  Glistening  is  very  unfavor- 
able. If  cracked,  it  points  to  kidney  trouble.  A  scarlet 
tongue  denotes  acute  inflammation,  usually  of  the  stomach, 
especially  if  red  along  the  edges  and  the  tip.  A  lead-colored 
tongue  is  found  in  cholera  and  sometimes  in  malignant  dis- 
ease of  the  stomach.  If  combined  with  thrush  it  denotes 
death. 

A  sharp,  pointed  tongue  is  observed  in  meningitis.  A 
tremulous  tongue  is  seen  in  many  acute  diseases  and  in 
cerebral  involvement. 

White  fur  on  the  tongue,  through  which  project  bright 
red  and  prominent  papilla?,  usually  called  "strawberry 
tongue,"  is  seen  in  the  early  stage  of  scarlet  fever. 

If  the  tongue  clears  slowly,  commencing  at  the  tip  and 
edges,  leaving  a  natural  appearance,  permanent  recovery 
can  be  expected.  If  the  fur  comes  off  in  patches,  leaving  a 
smooth  red  surface,  recovery  will  be  slow,  but  if  it  disap- 
pears rapidly,  leaving  a  shiny  cracked  surface,  it  is  unfa- 
vorable. 

A  bitter  taste  indicates  errors  of  diet  or  the  use  of 
drugs. 

CONGENITAL  DEFECTS 

Congenital  defects  are  divided  into:  (a)  Congenital 
fissures  or  bifid  tongue,  due  to  a  failure  of  the  branchial 
arches  which  go  to  form  the  tongue  in  embryonic  life  to 
coalesce.     This  is  a  very  rare  condition. 

(b)  Ankyloglossia,  or  tongue  tie,  not  a  frequent  deform- 
ity ;  a  result  of  shortness  of  the  f renum  or  of  its  attachment 
too  far  forward  toward  the  tip. 

(c)  Abnormally  long  frenum  with  lax  attachments  be- 
tween the  under  surface  of  the  tongue  and  posterior  sur- 
face of  the  mandible,  allowing  the  tongue  to  drop  back 
against  the  wall  of  the  pharynx  and  over  the  glottis,  inter- 
fering with  the  respiratory  act. 


148  DISEASES    OP    THE    TONGUE 

(d)  Abnormalities  in  size. — The  tongue  may  be  either 
too  large,  too  small  or  congenitally  absent,  cases  of  which 
kind  have  been  reported.  An  abnormally  large  tongue  is 
called  macroglossia  and  is  generally  congenital,  but  does 
not  attract  attention  for  the  first  year.  The  growth  is  usu- 
ally confined  to  the  apex.  It  is  a  hyperplasia  of  the  con- 
nective tissue.  The  tongue  sometimes  grows  to  enormous 
size,  even  extending  beyond  the  teeth  for  some  distance. 


Fig.  26. — Hypertrophy  of  the  Tongue.     (Bryant.) 

Its  size  changes  the  normal  dental  arch  and  every  proximal 
tissue  is  distorted.  That  part  of  the  tongue  which  pro- 
trudes and  is  exposed  to  the  atmosphere  becomes  parched 
and  brown,  losing  its  normal  characteristics. 

Treatment.— The  operation  for  ankyloglossia  consists  in 
elevating  the  tongue  and  cutting  the  band  with  scissors, 
taking  care  to  point  the  scissors  downward,  so  as  to  avoid 
the  ranine  artery. 

Treatment  for  macroglossia  consists  in  the  amputation 
of  sufficient  of  the  tongue  to  reduce  it  to  a  normal  size.  This 
is  done  by  first  passing  ligatures  through  the  sides  of  the 
tongue  so  as  to  draw  it  forward,  when  with  a  stout  scissors 


ACQUIRED   AFFECTIONS  149 

a  V-shaped  section  is  cut  from  the  center.  The  hemorrhage 
is  controlled  and  the  side  flaps  adjusted  and  sutured.  Re- 
pair follows,  and  no  return  is  expected. 

ACQUIRED  AFFECTIONS 

Acquired  affections  of  the  tongue  may  be  divided  into : 

Acute  (Ludwig's  angina). 


Inflammations ,   ^t        .     ,.  ^  ^  •   \ 

Chronic  (leucoplakia) 

r  Mechanical. 

Injuries \  Thermic. 

y  Chemical. 

r  Benign  lingual  goiter. 

Tumors J  Malignant. 

[  Specific. 

Inflammations 

Glossitis,  or  inflammation  of  the  tongue,  may  be  acute 
or  chronic. 

Acute  Inflammations 

The  acute  form  may  be  confined  to  the  mucous  mem- 
brane or  to  the  deeper  structures  and  to  the  floor  of  the 
mouth.  When  it  is  located  in  the  mucous  membrane,  it  is 
generally  associated  with  a  stomatitic  erysipelas,  or  is  a 
result  of  other  infections.  The  tongue  becomes  red,  swollen 
and  painful,  the  salivation  is  profuse,  and  a  muco-purulent 
fluid  is  discharged.  Swallowing  and  talking  are  performed 
with  effort.  The  pulse  is  frequent,  the  temperature  high, 
and  there  is  considerable  constitutional  disturbance.  Deep 
inflammation  or  parenchymatous  glossitis  may  develop 
without  any  assignable  cause,  although  it  is  usually  asso- 
ciated with  suppurative  process  about  the  mouth  or  jaws, 
or  is  caused  by  injuries.  Abscess  formation  is  liable  to 
follow. 


150  DISEASES    OF    THE    TONGUE 

Treatment.— Treatment  consists  in  removing  the  cause 
wlien  it  is  due  to  secondary  infection,  and  when  an  inocula- 
tion has  occurred  vigorous  local  treatment  must  be  given. 
Local  astringents  are  of  value.  Hot  water  up  to  tolerance, 
continuously  held  in  the  mouth,  will  destroy  infections  very 
rajDidly.  Just  as  the  colony  of  bacteria  causing  the  trou- 
ble is  destroyed,  active  symptoms  will  subside.  This  does 
not  mean  that  recovery  will  follow,  for  reinfection  from  a 
latent  colony  may  cause  a  return  of  active  symptoms.  For 
this  reason,  treatment  must  be  persistent  and  continuous, 
until  there  is  some  assurance  that  the  improvement  is  per- 
manent. 

Ludwig's  Angina.— This  condition  is  an  acute  infection 
of  the  deeper  structures  of  the  tongue  and  floor  of  the 
mouth,  usually  associated  with  infection  from  inflammatory 
conditions  of  the  teeth  or  mandible.  It  may,  however,  de- 
velop without  the  presence  of  other  infections  about  the 
mouth.  It  may  go  on  to  suppuration  and  abscess  formation, 
or  may  subside  short  of  this.  The  surface  of  the  tongue 
may  not  be  involved.  The  disease  produces  local  signs  be- 
fore general  symptoms,  and  attention  may  first  be  attracted 
by  a  swelling,  which  may  be  either  below  the  jaw  in  the  sub- 
maxillary region  or  posteriorly  over  the  parotid  region. 
The  hard,  ''board-like"  character  of  the  swelling  is  almost 
pathognomonic.  Sometimes  the  skin  is  pale,  sensitiveness 
not  marked,  and  the  temperature  raised  but  one  or  two  de- 
grees. In  other  cases  the  skin  may  be  a  dusky  red,  tender, 
hard,  and  painful  to  the  touch,  and  the  temperature  high, 
102°  or  103°.  Swelling  of  the  floor  of  the  mouth,  pushing 
the  tongue  upward  to  the  roof  and  forward,  with  difficulty 
in  swallowing  and  some  difficulty  in  breathing,  are  early 
noticed.  Chills  may  occur,  and  dirty,  offensive  pus  may 
break  into  the  mouth  near  the  molar  teeth.  The  swelling 
may  extend  down  to  the  clavicle  and  up  to  the  temple,  and 
a  large  abscess  may  form  beneath  the  lower  jaw.  Death 
may  occur  early  from  involvement   of  the  larynx,   with 


ACQUIRED   AFFECTIONS 


151 


Fig.  27. — Ludwig's  Angina. 


edema  and  dyspnea  developing  rapidly,  this  involvement 
being  indicated  first  by  a  hoarseness  of  the  voice  and  then 
by  its  loss.  The  progressive  in- 
volvement of  the  deeper  tissues 
should  settle  at  once  the  question 
of  diagnosis. 

Treatment  consists  in  the  use 
of  tincture  of  iodin  in  the  tissues 
of  the  mouth  to  destroy  the  bac- 
teria. If  an  abscess  develops  it 
should  be  incised,  care  being 
taken  not  to  sever  blood  vessels, 
which  are  numerous  about  the 
tongue.  Median  incision  from 
below  is  to  be  preferred.  Drain- 
age either  with  rubber  or  gauze 
should  be  instituted.  Tracheo- 
tomy may  be  required  to  prevent  a  fatal  termination. 

Illustrative  Case. — In  the  case  illustrated  the  disease 
ran  a  very  acute  course  with  considerable  temperature.  The 

photographs  shown  were  taken 
one  week  after  the  onset.  At  the 
time  the  case  was  seen,  tincture 
of  iodin  had  been  used  freely 
throughout  the  oral  cavity  and 
instructions  were  left  to  use  it 
three  times  in  twenty-four  hours. 
Symptoms  had  not  advanced  at 
the  end  of  this  time,  and  the 
iodin  was  continued.  To  our 
great  satisfaction  the  infiltration 
diminished,  the  symptoms  sub- 
sided, and  the  patient  recovered 
without  operation.  The  theory 
of  the  use  of  iodin  is  that  it  is  absorbed  from  the  mucous 
membrane  of  the  mouth  by  the  lymphatics  and  passes  along 


Fig.  28. — Ludwig's  Angina. 


152  DISEASES    OF    THE    TONGUE 

the  same  lymph  channels  which  have  been  infected  at  the 
beginning  of  the  disease. 

Chronic  Inflammations 

Chronic  inflammations  per  se  are  rare,  for  they  are  gen- 
erally assignable  to  specific  or  other  causes,  the  tongue  con- 
dition being  only  a  symptom,  Icthyosis  linguae,  or  leucopla- 
kia,  is  a  chronic  localized  thickening  of  the  mucous  mem- 
brane of  the  tongue,  which  may  be  caused  by  excessive 
smoking,  the  use  of  alcohol  as  a  beverage,  or  by  other  irri- 
tants, and  by  syphilis.  Beginning  as  an  inflammation,  it 
progresses  to  the  formation  of  ulcers,  which  may  persist 
and  develop  into  deep  destructions.  Mixed  infection,  as 
with  the  tubercle  bacillus  and  true  lupus  of  the  tongue, 
may  follow,  and  epithelioma  has  been  preceded  by  this  form 
of  inflammation.  A  marked  symptom  is  dryness  of  the 
tongue,  the  surface  is  red,  and  sometimes  furrowed,  during 
the  early  stage  before  ulcerations  begin. 

Treatment  consists  in  the  removal  of  the  cause,  the  with- 
drawal of  alcohol  and  tobacco,  etc.  The  curettement  of  a 
tuberculous  ulcer  is  good  practice.  If  it  is  syphilitic,  mixed 
treatment  should  be  given,  with  antiseptic  mouth  washes 
for  cleansing  purposes.  If  epithelioma  develops,  that  part 
of  the  tongue  which  is  involved  should  be  amputated.  For 
details  see  chapters  on  these  subjects. 

Leucoplakia  of  the  Mouth.^ — This  condition  is  so  named 
because  of  its  white  appearance.  It  was  first  lucidly  de- 
scribed by  Schwimmer,  and  Hutchinson  called  it  leucoma. 
By  other  writers  it  has  been  called  lingual  psoriasis,  lin- 
gual ichthyosis  and  smoker's  tongue.  It  is  usually  located 
on  the  upper  surface  of  the  tongue  anterior  to  the  circum- 
vallate  papillae.  It  is  also  found  along  the  sides  and  under 
the  tip  of  the  tongue.  It  may,  however,  be  found  on  other 
parts  of  the  mouth.  It  is  an  idiopathic  disease  character- 
ized by  milk-white,  opaque  plaques  slightly  elevated  above 
the  surface.    At  first  small  patches  are  found,  which  dur- 


ACQUIRED   AFFECTIONS 


153 


ing  several  montlis  become  larger  and  coalesce,  covering 
the  entire  tongue  or  cheek.  The  patches  are  at  first  soft 
and  smooth,  but  later  become  hard  and  feel  rough  and 
warty.  The  surface  may  become  furrowed  or  ulcerative 
and  bleeds  during  mastication  or  following  slight  injury. 

The  plaques  appear  to  be  many  layers  of  squamous  epi- 
thelium piling  up,  instead  of  desquamating,  as  is  usually 

the  case.  The  tendency  is  to 
harden,  similar  to  skin  horns 
or  cornification.  During  the 
early  stage  the  papillae  are 
not  involved  and  plaques 
may  be  desquamated  without 
hemorrhage.  As  the  disease 
advances,  the  deeper  struc- 
tures are  included  in  the 
hyperplastic  changes,  about 
which  will  be  found  an  area 
of  leucocytic  infiltration. 
When  not  checked  by  treat- 
ment, this  epithelial  prolifer- 
ation continues  and  carcino- 
ma is  the  result. 

The  etiology  is  not  well 
understood.  It  is  almost  al- 
ways developed  in  men  who 
smoke,  although  about  ten  per  cent,  of  the  cases  are  found 
in  women,  many  of  whom  smoke.  It  is  definitely  known  that 
smoking  stimulates  the  formation  of  the  patches,  which  will 
disappear  during  abstinence.  Symptoms,  other  than  the 
patch,  are  absent  during  the  early  course.  Later  there  is 
some  pain  and  tenderness.  As  the  plaques  become  deeper 
and  larger,  symptoms  are  intensified.  If  the  condition 
passes  over  into  malignancy,  the  symptoms  are  those  of  a 
carcinoma. 

A  syphilitic  leucoplakia  is  described  by  some  authors 


Fig.  29. — Leucoplakia  Lingua.  (Re- 
production in  black  and  white  from 
Jacobi's  dermachromes.  By  per- 
mission of  The  Rebman  Company.) 


154  DISEASES    OF    THE    TONGUE 

in  connection  with  the  general  subject,  and  since  syphihtic 
lesions  of  the  tongue  are  described  in  detail  in  the 
chapter  on  this  subject,  further  description  is  unnecessary 
here. 

Diagnosis  must  be  made  from  syphilitic  patches,  infil- 
tration, gumma  and  epithelioma.  In  the  syphilitic  lesions 
the  history  must  be  considered.  (See  syphilis  of  the 
mouth.)  Leucoplakia  begins  gradually  and  painlessly  and 
grows  continuously.  In  syphilis  the  growth  is  rapid  and  is 
usually  sensitive.  The  glands  of  the  neck  are  enlarged  in 
syphilis,  but  not  so  in  leucoplakia.  It  more  nearly  resem- 
bles carcinoma,  in  which  condition  the  white  patches  are 
almost  identical.  In  the  latter  the  whiteness  is  pearly  and 
resembles  that  of  a  phenol  burn.  In  leucoplakia  there  is  a 
dead  whiteness. 

Treatment  should  be  radical  and  prompt.  Fournier 
says  that  thirty  per  cent,  of  cases  become  carcinoma  when 
permitted  to  advance  to  the  deeper  tissues.  The  use  of 
escharotics,  as  chromic  and  other  acids,  affords  no  per- 
manent curative  result  and  should  not  be  dejDended 
upon.  Smoking  and  the  use  of  tobacco  must  be  forbidden. 
Mouth  washes  must  be  used.  Ice  may  be  used  to  control 
pain. 

The  X-ray  has  furnished  a  therapeutic  agent  of  some 
value.  The  Pacquelin  cautery  is  to-day  the  most  acceptable 
means  of  treatment.  Repeated  burnings  should  be  done 
until  all  of  the  patches  and  more  deeply  involved  tissues  are 
destroyed.  The  operations  may  be  done  under  cocain  an- 
esthesia. 

Injuries 

Mechanical  injuries  may  be  the  result  of  punctures,  of 
bites  from  falls  with  a  pipe  or  other  article  in  the  mouth, 
or  while  the  tongue  is  caught  between  the  teeth,  or  of  bites 
during  epileptic  seizures.  When  the  incisions  or  lacerations 
are  deep,  a  considerable  vessel  may  be  injured,  resulting 


ACQUIRED   AFFECTIONS  155 

in  alarming  hemorrhage  and  requiring  ligation.  Such  cases 
should  be  treated  with  antiseptic  washes,  etc.,  as  wounds 
are  treated  on  other  parts  of  the  body.  The  edges  should 
be  adjusted  with  fine  catgut.  Union  is  the  general  result, 
and  repair  follows  without  complication. 

A  chronic  irritation  of  the  tongue  may  result  from  the 
projecting  edge  of  a  decayed  tooth  which  has  been  neg- 
lected. The  constant  rubbing  of  such  a  sharp  point  against 
the  tongue  produces  a  granular  surface  which  persists  until 
the  tooth  is  filled  or  extracted.  It  is  very  important  that 
either  one  or  the  other  of  these  should  be  done,  as  it  is 
claimed  that  carcinoma  frequently  results  from  such 
cases. 

As  to  the  thermic  injuries,  heat,  in  the  form  of  food  or 
otherwise,  and  chemicals  may  come  in  contact  with  the  mu- 
cous membrane,  resulting  in  destruction  and  ulceration. 
Scalds  and  burns  from  the  introduction  into  the  mouth  of 
hot  food  or  drink  cause  superficial  destruction  of  the  mu- 
cous membrane,  and  the  ulcer  resulting  may  be  mistaken 
by  the  dentist  for  a  more  severe  affection  unless  the  history 
be  considered.  Abscess  of  the  tongue  is  not  common  and 
is  mostly  that  following  Ludwig's  angina,  and  has  already 
been  considered.  If  from  other  causes,  the  treatment  should 
be  the  same.  The  lesions  caused  by  drinking  of  any  cor- 
rosive liquid,  as  acid  or  alkaline  solutions,  etc.,  with  sui- 
cidal intent  or  accidentally,  result  in  destruction  of  the 
tongue.    The  treatment  already  outlined  is  sufficient. 

Other  ulcerations  of  the  tongue  are  due  to  particular 
causes,  as  syphilis,  tuberculosis  or  cancer,  and  are  consid- 
ered under  these  several  heads. 

Lingual  goiter  is  an  enlargement  of  the  lingual  tonsil, 
which  is  situated  at  the  base  of  the  tongue.  It  varies  in 
size  in  proportion  to  the  length  of  time  it  remains  without 
treatment.  The  tumors  are  bi-lobed  and  are  firm  but  elas- 
tic to  the  touch. 

Microscopically  they  resemble  thyroid  tissue  containing 


156  DISEASES    OF    THE    TONGUE 

colloidal  material  which  is  confined  to  the  sini,  which  are, 
in  turn,  found  to  be  lined  with  cuboid  epithelium. 

These  conditions  are  rare  and  must  be  differentiated 
from  gummata  before  breaking  down,  and  cysts  of  other 
glands  of  the  tongue.  Occasionally  they  are  due  to  extrav- 
asation of  blood,  but  they  develojD  more  rapidly.  They 
must  also  be  differentiated  from  dermoid  cyst,  which  de- 
velops more  rapidly,  pits  on  pressure,  is  not  so  vascular, 
and  is  usually  yellow  when  found  upon  the  dorsum  of  the 
tongue. 

A  lingual  goiter  develops  very  slowly  and  is  located  at 
the  center  of  the  base  of  the  tongue  about  as  far  forward  as 
the  foramen  cecum.  This  surface  is  smooth,  pinkish  in 
color,  and  covered  with  mucous  membrane,  showing  vascu- 
lar network. 

Treatment  consists  in  removal  by  surgical  operation. 
Tracheotomy  is  usually  necessary  on  account  of  extensive 
hemorrhage  which  follows,  and  anesthetic  is  given  through 
the  tracheotomy  tube. 

Tumors 

Tumors  of  the  tongue  are  benign  and  malignant. 

Benign  tumors  are  dermoid,  lipoma,  fibroma,  papilloma 
and  encondroma.  Under  the  same  head  may  be  included 
other  enlargements  of  the  tongue,  such  as  nevus,  macro- 
glossia,  and  retention  cysts,  such  as  ranula  and  the  reten- 
tion of  normal  secretion  from  the  sebaceous  glands  and  the 
glands  of  Nuhn,  all  of  which  have  been  considered  under 
general  heads. 

Malignant  diseases  of  the  tongue  are  principally  epi- 
thelial carcinomata.  They  develop  in  advanced  life,  be- 
tween forty  and  sixty  years  of  age,  and  about  ninety  per 
cent,  are  in  males. 

Barker  reports  two  hundred  and  ninety-three  cases,  and 
two  hundred  and  forty-seven  were  in  men.  St.  Thomas's 
Hospital  treated  one  hundred  and  sixty  cases,  sixteen  of 


ACQUIRED   AFFECTIONS 


157 


which  were  women.  The  causes,  as  they  have  been  deter- 
minable, are  lacerations  of  the  tongue  from  ragged  teeth, 
smoking,  trauma,  and  injuries  of  the  tongue  by  the  teeth 
during  falls.  Tuberculous  and  syphilitic  ultercations  are 
followed  by  the  development  of  epithelioma.    Leucoplakia 


Fig.  30. — Epithelioma  of  the  Tongue.     Case  of  Dr.  Jerome  Longenecker, 

Philadelphia,  Pa. 

and  other  chronic  maladies  of  the  tongue  apparently  pre- 
dispose to  cancer.  The  disease,  usually  beginning  on  the 
dorsal  surface  of  the  tongue,  extends  to  deeper  structures, 
involving  the  sublingual  tissues,  and  later  on  extends  down 
into  the  cervical  glands.  From  four  to  six  months  may 
pass  before  the  patient  consults  a  surgeon,  so  insidious  is 
the  onset. 


158  DISEASES    OF    THE    TONGUE 

Diagnosis.— Diagnosis  is  of  the  greatest  importance 
since  many  mistakes  are  made.  It  is  wise,  and,  indeed,  es- 
sential, that  a  section  of  the  suspected  area  be  removed  for 
microscopic  examination  before  any  important  operation  be 
done  on  the  tongue.  Cocain  should  be  used  so  that  a  piece 
of  sufficient  size  may  be  obtained.  The  cut  should  be 
through  the  edge  of  the  ulcer,  and  at  a  right  angle  with  the 
surface  of  the  sore.  Esmarch  called  attention  to  the  many 
mistakes  that  had  been  made  in  the  removal  of  parts,  often 
of  great  importance,  under  diagnosis  of  malignancy,  when 
the  disease  afterward  proved  to  be  syphilitic,  or  even 
merely  inflammatory.  He  thought  that  many  syphilomata 
had  been  removed  as  sarcomata. 

Di/ferential  diagnosis  between  syphilis  of  the  tongue 
and  cancer  is  sometimes  difficult.  Anderson  called  atten- 
tion to  the  fact  that  precancerous  conditions,  which  at  the 
outset  may  appear  benign,  have  grafted  over  them  cancer- 
ous conditions.  He  says:  ''Therefore,  no  surgical  lesion 
of  the  tongue,  unless  it  be  of  a  merely  transitory  nature, 
must  be  regarded  as  unimportant. 

Treatment.— Operative  treatment  is  the  only  means 
which  promises  anything  for  these  cases — the  complete 
eradication  of  the  ulcer  and  the  surrounding  tissues  so  that 
all  involved  structure  is  removed. 

OiDeration  involves  the  removal  of  a  section  of  the 
tongue.  When  the  disease  is  on  one  side,  the  other  side 
need  not  be  removed  unless  the  infiltration  is  very  close  to 
the  median  line.  Partial  and  complete  amputation  of  the 
tongue  are  well  known  procedures.  In  partial  operations 
the  operation  is  done  through  the  oral  orifice.  After  cleans- 
ing the  mouth,  the  patient  is  anesthetized.  The  tongue  is 
now  secured  with  a  silk  thread  or  volsellum  forceps.  The 
wire  clamp  forceps  are  most  efficient,  and  not  only  serve  to 
retract  the  tongue,  but  also  control  the  hemorrhage,  which 
is  generally  profuse.  A  mouth  gag  is  now  inserted.  With 
a  stout  scissors  a  V-shaped  section  of  the  tongue  is  removed. 


ACQUIRED    AFFECTIONS  159 

It  may  be  necessary  to  sever  the  frenum.  The  bleeding 
vessels  are  caught  up  with  hemostats  and  ligated.  The  lat- 
eral flaps  are  now  approximated  and  held  in  position  with 
silkworm-gut  sutures.  Amputation  of  the  entire  tongue 
may  be  performed  after  the  methods  of  Kocher,  Barwell, 
Billroth,  etc.,  or  modified  to  suit  the  case  or  the  operator. 


CHAPTER  XVI 

SUEGICAL    DISEASES    AND    IISTJUEIES    OF    THE    FACE 

Nothing  affords  so  much  information  as  to  the  health 
and  character  of  a  new  patient  as  a  glance  at  the  face.  A 
clean  skin,  clear  eye  and  open  countenance  are  evidences 
which  speak  for  themselves.  When  these  things  are  not 
present,  other  avenues  for  gaining  information  must  be 
used.  Experience  leads  to  a  knowledge  of  the  character  of 
peoj)le.  Pathological  conditions  of  the  skin,  however,  are 
learned  by  accurate  study.  The  simple  conditions  about  the 
face  which  should  be  understood  and  recognized  by  the 
dentist,  and  which  should  not  be  mistaken  for  malignant, 
specific  or  tuberculous  eruptions,  may  be  described  as  fol- 
lows : 

Erythema,  or  rose  rash,  is  a  marked  redness  of  the  skin, 
due  to  congestion  of  the  smaller  vessels.  It  apjaears  in 
many  forms :  as  a  diffused  redness  in  small  and  large  spots 
and  in  nodes.  The  redness  disappears  on  pressure.  It  is 
usually  due  to  digestive  disturbance  and  disappears  when' 
this  is  corrected. 

Petechice  are  small  red  spots  formed  by  effusion  of 
blood,  as  in  typhoid  and  pur^Dura.  They  resemble  insect 
bites. 

A  macula  is  a  stain  or  discolored  spot  of  the  skin,  not 
elevated  above  the  surface,  which  does  not  disappear  on 
pressure.  When  due  to  hemorrhage  it  is  known  as  purpura 
hemorrhagica. 

A  papule  is  a  small,  circumscribed,  solid  elevation  of 
skin.    It  does  not  contain  liquid. 

160 


DISEASES  OF  THE   SEBACEOUS   GLANDS  161 

A  vesicle,  sometimes  called  a  bulla,  blister  or  bleb,  is  a 
small  circumscribed  elevation  of  skin  containing  serous 
liquid. 

A  pustule  is  a  small,  circumscribed  elevation  of  skin  con- 
taining pus.  It  is  typical  in  acne,  chicken-pox  and  smallpox. 
It  is  usually  preceded  by  the  foregoing  conditions,  in  order : 
macule,  papule  and  vesicle. 

Crustaceous  conditions  succeeding  pustules,  abrasions 
and  ulcerations  are  solid  layers  of  matter  caused  by  the 
drying  of  the  secretions  or  body  exudates. 

Dermatitis  is  any  infection  of  the  skin,  regardless  of  the 
cause  or  course.  It  is  an  indefinite  term  requiring  little  con- 
sideration under  the  bacteriological  classification  of  dis- 
ease. Mechanical  dermatitis,  however,  requires  special 
mention.  It  is  caused  by  some  form  of  drug  or  mechanical 
irritant,  escharotics,  acids,  etc.,  which  accidentally  or  other- 
wise come  into  contact  with  the  skin,  destroying  the  epi- 
dermis and  setting  up  irritation,  and  it  cannot  be  considered 
true  inflammation  unless  infection  occurs.  Mechanical 
dermatitis  usually  subsides  without  special  treatment  when 
the  cause  is  removed. 


DISEASES  OF  THE  SEBACEOUS  GLANDS 

Acne  vulgaris  is  an  infection  of  the  sebaceous  glands 
with  a  tendency  to  the  formation  of  pustules.  It  appears 
about  puberty  and  disappears  usually  at  about  twenty-five 
years  of  age.  The  eruption  is  most  profuse  over  the  cheeks, 
forehead  and  nose,  but  may  also  extend  over  the  breast, 
shoulders  and  back. 

Comedo,  a  most  simple  form,  commonly  called  black- 
heads, is  an  accumulation  of  sebum  in  the  duct.  The  come- 
done  is  white,  the  black  top  being  due  to  a  discoloration 
from  dust  particles. 

Papular  acne  usually  begins  from  a  comedo  and  is  due 
to  infection. by  some  form  of  pyogenic  bacteria.     It  is  at 


162  SURGICAL    DISEASES    OF    THE    FACE 

first  red  and  tender,  but  becomes  less  active  later  on,  and,  as 
pus  formation  is  established,  is  known  as  pustular  acne. 
Tlie  pustule  is  surrounded  by  an  inflammatory  base  which 
disappears  as  the  pustule  dries  into  a  crust,  and  is  shed  in 
a  few  days,  leaving  a  purple  pit.  The  pustules  become  quite 
tender,  especially  when  they  are  on  the  nose.  All  of  these 
conditions  destroy  the  personal  appearance  of  the  individ- 


FiG.  31. — Acne  Vulgaris.     (Dr.  Geo.  C.  Johnston.) 

ual  thus  affected,  and  it  is  quite  desirable  that  an  effective 
treatment  be  instituted  to  eradicate  them.  They  must  be 
differentiated  from  tuberculous  and  syphilitic  eruptions, 
whose  characteristics  are  described  under  those  heads.  The 
history  is  most  important. 

Treatment  should  be  directed  to  an  improvement  of  the 
general  health  and  the  administration  of  alteratives  and 
reconstructives.  Calcium  sulphid  in  grain  doses  three 
times  a  day  is  of  undoubted  value.  Locally  the  pustules 
may  be  curetted  away,  but  these  local  operative  procedures 


DISEASES  OF   THE   SEBACEOUS   GLANDS  163 

should  be  postponed  until  constitutional  treatment  has  been 
tested,  since  scars  usually  follow  the  use  of  surgical  means. 
Applications  of  quite  hot  absorbent  cotton  saturated  in 
boric  acid  solution  is  a  most  satisfactory  treatment.  The 
applications  should  be  continued  for  several  hours  each  day 
to  be  effective. 

Milium  is  an  accumulation  of  sebum  near  the  orifice  of 
a  duct  and  contains  but  thin  covering.  These  accumulations 
are  usually  the  size  of  a  pinhead,  but  may  be  larger.  They 
are  found  most  frequently  on  the  face  and  about  old  scars, 
but  may  appear  on  any  part  of  the  body. 

Sebaceous  cysts  develop  wherever  such  glands  are 
found,  usually  in  the  face,  scalp,  back  of  neck  and  back. 
They  contain  a  cheesy  material  with  sufficient  consistency 
to  readily  stand  alone  when  removed  from  the  capsule. 
They  are  usually  small,  but  may  grow  to  considerable 
size.  The  centers  are  always  adherent  to  the  skin 
at  the  original  location  of  the  duct,  but  they  are 
freely  movable  above  the  deep  tissues.  Treatment  con- 
sists in  complete  removal  of  the  sac,  as  otherwise  it 
will  return. 

Papilloma  include  all  those  benig-n  or  rough  growths  of 
the  skin  and  mucous  membrane  known  as  warts,  villous 
growths  and  horny  excrescences. 

VerruccB,  or  warts,  are  hypertrophies  of  the  skin  or  mu- 
cous membrane,  due  to  persistent  irritation.  They  occur 
singly  and  in  crops,  growing  in  various  shapes,  sometimes 
broad  and  flat,  with  smooth  surfaces  or  having  villi  project- 
ing from  the  surface,  and  sometimes  assuming  a  cauli- 
flower shape.  The  surface  is  covered  with  epithelium,  some- 
times piled  up  in  many  layers,  constituting  the  principal 
portion  of  the  growth.  Treatment  consists  in  removal  with 
nitric  or  chromic  acid  or  by  excision. 

Horns  from  the  skin  and  nails  grow  from  (a)  scars,  and 
are  composed  of  a  hardened  piling-up  of  epithelial  tissue 
constituting  the  cicatrix;  (b)  sebaceous  tumor,  caused  by 


164 


SURGICAL    DISEASES    OF    THE    FACE 


the  contents  gradually  hardening  as  it  exudes  from  be- 
neath; (c)  nail  horns,  or  abnormal  growths  of  the  finger- 
and  toe-nails  of  invalids;  (d)  warty  horns,  resembling  epi- 
thelial warts,  except  that  the  papillomatous  projections  cal- 
cify.   They  grow  from  the  forehead  or  scalp  and  may  as- 


FiG.  32. — Blastomycosis.     (Hyde  &  Montgomery.) 


sume  enormous  lengths.     Treatment  consists  in  removal. 
The  sebaceous  horns  are  dissolved  by  liquor  potassae. 


PARASITIC  DISEASES  OF  THE  SKIN 

The  parasitic  diseases  of  the  face  which  are  of  special 
interest  to  the  dentist  and  which  should  be  differentiated 
from  other  conditions  are : 

(a)  Tinea  trichophytina,  or  ringworm,  due  to  the  tri- 
chophyton, a  contagious  parasite,  beginning  as  a  brown 
spot  slightly  elevated,  with  a  tendency  to  desquamation, 
and  gradually  increasing  in  size  as  the  center  repairs,  leav- 
ing crescentic  or  concentric  areas.  The  disease  is  most 
common  in  children.  In  addition  to  the  characteristic  ar- 
rangement of  the  eruption,  the  one  prominent  symptom  is 
itchiness. 

(b)  Tinea  sycosis,  commonly  known  as  barber's  itch,  is 
similar  to  the  former,  except  that  it  is  located  in  the  beard. 


PARASITIC    DISEASES    OF    THE    SKIN  165 

Treatment  involves  the  use  of  some  parasiticide.  Sodium 
hyposulphite  is  no  doubt  the  best,  a  solution  of  one  dram 
to  the  ounce  being  applied  to  the  affected  parts.  Other 
remedies,  such  as  tincture  of  iodin,  carbolic  acid,  etc.,  are 


Fig.  33. — Tinea  Sycosis.     (Dr.  Geo.  C.  Johnston.) 

effective,  but  the  first-named  drug  causes  no  pain  and  for 
this  reason  is  to  be  preferred. 

(c)  Scabies,  or  itch,  is  due  to  an  animal  parasite,  ap- 
pearing between  the  fingers,  where  the  skin  is  thin,  and  has 
least  resistance.  It  appears  in  many  very  small,  dark  red 
spots  in  continuous  chain,  showing  the  route  of  the  parasite 
as  it  burrows  its  way  under  the  epidermis.  Treatment  con- 
sists in  application  of  hot  water,  followed  by  sodium  hypo- 
sulphite solutions,  or  sulphur  ointment,  for  three  or  four 


166  SURGICAL    DISEASES    OF    THE    FACE 

days,  after  which  a  very  hot  bath  is  taken  and  the  clothing 
is  entirely  renewed. 

ACUTE  INFECTION  OF  THE  SKIN 

Furuncle,  commonly  known  as  a  ''boil,"  is  an  acute  in- 
fection of  the  glands  of  the  skin  or  hair  follicles,  terminat- 
ing, as  a  rule,  in  the  necrosis  of  a  central  area,  which  comes 
away  en  masse  and  is  known  as  the  "core,"  Staphylococ- 
cus pyogenes  aureus  is  the  germ  found. 

The  trouble  may  be  single,  when  it  is  generally  quite 
large,  or  it  may  be  multiple,  the  individual  infections  ap- 
pearing simultaneously  or  successively,  varying  in  size 
from  a  pea  to  a  walnut.  The  affection  is  quite  common  and 
the  course  well  known.  It  may  be  described  as  beginning 
in  an  induration  which  is  painful,  tender  and  red,  u|3on  the 
apex  of  which  is  usually  seen  a  small  vesicle  at  a  hair  folli- 
cle, showing  the  point  of  infection.  As  the  central  mass 
becomes  necrotic,  as  a  result  of  withdrawal  of  nutrition, 
there  is  formed  about  it  a  suppurating  area.  Around  this 
the  tissues  become  infiltrated,  red  and  tender.  In  several 
days  it  points,  which  means  that  the  zone  of  pus  approaches 
the  surface.  This  spontaneously  erupts  if  not  incised,  and 
but  little  pus  escapes.  The  necrotic  center  can  now  be  seen, 
which  in  thirty-six  to  forty-eight  hours  is  thrown  off,  leav- 
ing a  granular  cavity  healing  from  the  bottom  in  a  few 
days.  In  some  individuals,  or  when  the  boil  is  large,  the 
pain  and  infection  may  result  in  fever,  loss  of  appetite,  and 
general  impairment  of  normal  vitality.  The  treatment  may 
be  of  two  kinds:  (a)  Abortive,  which  consists  in  the  con- 
tinuous use  of  heat  from  a  coil  or  hot-water  bottle  at  a  tem- 
perature of  110°  F.  for  six  hours.  This  treatment  can  only 
be  effective  when  it  is  instituted  before  suppuration  begins. 
Many  cases  have  been  cut  short  of  suppuration  by  this 
method  by  the  author.  The  theory  of  this  treatment  is  that 
the  colony  of  staphylococcus  pyogenes  aureus  which  pro- 


WOUNDS  OF  THE  FACE  AND  MOUTH     167 

duces  the  inflammation  is  destroyed  by  the  heat,  (b)  If 
suppuration  has  begun,  incision  may  be  made  to  hasten 
repair.  The  cut  must  extend  down  into  the  necrotic  area, 
which  must  be  curetted  away,  the  cavity  swabbed  with  pure 
alcohol  or  tincture  of  iodin  and  packed.  Such  an  operation 
should  be  followed  in  a  few  hours  by  subsidence  of  all  active 
symptoms.  Secondary  infections  are  usual,  and  should  be 
treated  in  the  same  way. 

Carbuncle  is  one  or  more  furuncles,  of  large  size,  run- 
ning a  more  severe  course  with  more  marked  constitutional 
symptoms  than  ''boils,"  and  ushered  in  by  a  chill.  What 
has  been  said  of  the  symptoms  of  furuncle  applies  to  car- 
buncle, except  that  they  are  intensified  many  fold.  The 
same  microorganism  is  found.  There  are  several  open- 
ings showing  the  multiform  character  of  the  trouble.  While 
"boils,"  as  a  rule,  do  not  endanger  life,  carbuncles  have  a 
grave  prognosis,  especially  when  they  develop  on  the  head 
or  face.  Treatment  here  also  may  be  considered  as  abor- 
tive and  operative.  Every  effort  should  be  made  to  cut 
short  the  course.  When  this  is  not  possible,  early  incision 
should  be  made.  This  must  be  thorough,  the  line  of  in- 
cision extending  so  as  to  include  every  orifice,  and  may  be 
crucial,  "V"-  or  "Y  "-shaped.  Curettement  and  irrigation 
with  tincture  of  iodin,  pure  alcohol  or  other  antiseptic  solu- 
tion, or  hot  water,  must  be  used  so  as  to  thoroughly  eradi- 
cate every  pocket  of  infection.  The  constitutional  treat- 
ment consists  in  the  use  of  anodynes  to  control  pain,  tonics, 
reconstructives  and  a  nutritious  and  stimulating  diet. 

WOUNDS  OF  THE  FACE  AND  MOUTH 

Wounds  of  the  face  do  not  differ  greatly  from  those  of 
other  parts  of  the  body,  and  are  classified  and  treated  as 
described  under  the  chapter  on  wounds. 

Incised  and  punctured  wounds  bleed  very  freely  owing 
to  the  extreme  vascularity  of  the  tissues  of  the  face,  but 


168  SUEGICAL    DISEASES    OF    THE    FACE 

for  the  same  reason  heal  readily,  and,  when  antiseptic  pre- 
cautions are  taken  and  the  skin  is  properly  adjusted,  they 
heal  with  smooth  scars.  Great  care  should  be  taken  in 
dressing  wounds  of  the  face — scars  are  very  noticeable  and 
the  cosmetic  appearance  is  a  matter  to  be  considered.  After 
cleansing  the  wound,  the  skin  should  be  neatly  adjusted 
with  horsehair  or  fine  catgut  suture.  A  small  curved  needle 
should  be  used,  as  large  needles  make  a  puncture  which 
alone  may  leave  a  scar,  and  they  sometimes  puncture  a 
blood  vessel  and  produce  considerable  hemorrhage.  A  small 
piece  of  antiseptic  gauze  should  be  placed  over  the  suture, 
held  in  j^osition  with  strips  of  adhesive  plaster.  Adhesive 
plaster  should  not  be  permitted  to  come  in  contact  with  the 
wound,  but  the  gauze  should  interpose.  Even  in  abrasion 
of  the  skin,  if  adhesive  j^laster  is  permitted  to  come  in  con- 
tact with  the  denuded  surface,  infection  is  very  likely  to 
occur.  The  suture  should  be  removed  on  the  sixth  or  sev- 
enth day,  or  just  as  soon  as  union  has  taken  place,  so  as 
to  avoid  stitch-hole  abscesses. 

Contusions  of  the  face  result  from  fist  blows,  kicks,  and 
falls,  and  are  followed  by  great  swelling  and  discoloration, 
especially  about  the  eyes,  a  condition  known  as  black  eye, 
which  is  a  form  of  ecchymosis.  AVlien  the  blow  is  directly 
over  a  bony  prominence,  a  hematoma  is  likely  to  occur,  and, 
when  care  is  not  taken  to  sterilize  the  wound,  even  if  it  be 
but  an  abrasion,  infection  is  likely  to  occur  and  suiDpuration 
of  the  hematoma  follow.  Severe  contusion  associated  with 
fracture  of  the  bones  of  the  face  and  punctured  wounds 
have,  as  a  not  infrequent  complication,  rupture  of  a  deep 
blood  vessel  and  alarming  hemorrhage,  or  a  perforation  of 
the  maxillary  or  another  sinus.  A  case  is  recalled  where  a 
blow  over  the  superior  orbital  ridge  resulted  in  fracture  of 
the  lorocess  into  the  frontal  sinus,  requiring  the  removal  of 
the  ridge  and  anterior  wall  of  the  sinus  upward  for  three- 
quarters  of  an  inch.  The  wound  healed  without  complica- 
tion or  sequela.    Gunpowder  stains  should  be  removed  at 


NEUROSES   OF   THE  FACE  169 

once,  under  local  or  general  anesthesia  if  necessary,  for  if 
allowed  to  remain  for  forty-eight  hours  they  become  per- 
manent. The  parts  should  be  scrubbed  with  a  stiff  flesh- 
brush,  using  a  one  per  cent,  solution  of  mercuric  chlorid. 
Gauze  saturated  with  flexible  collodion  makes  the  most  sat- 
isfactory dressing. 

Later  complications  of  the  wounds  of  the  face  are  neu- 
ralgia, contractures,  cramps  of  muscles,  twitching,  edema 
of  the  tongue  or  pharynx,  and  infection  either  in  the  form 
of  erysipelas  or  cellulitis.  Permanent  deformities  are  en- 
tropian  or  ectropian,  eversion  of  the  lips  and  contractions 
of  the  masseter,  temporal  or  other  muscles,  causing  occlu- 
sion. 

A  very  troublesome  variety  of  complication  of  w^ounds 
of  the  face  is  salivary  fistula,  usually  of  Stenson's  duct.  It 
is  treated  under  a  separate  head.  Anesthesia  of  the  face 
can  result  only  from  a  deep  injury  including  one  of  the 
branches  of  the  trifacial,  and  corresponds  to  the  area  of 
distribution  of  the  nerve  injured. 

Death  seldom  results  from  wounds  of  the  face,  but  ex- 
tensive deformity  is  not  uncommon.  Poison  wounds  of  the 
face,  such  as  stings  of  insects,  spiders,  etc.,  should  be  differ- 
entiated from  other  varieties  of  facial  blemishes,  especially 
of  a  sjDecific  nature.  The  reader  is  also  referred  to  the 
chapter  on  syphilitic  manifestations  on  the  face  and  mouth. 
Fracture  of  the  bones  of  the  face  is  considered  under  frac- 
tures. 

Burns  and  scalds  of  the  face  should  be  treated  as  out- 
lined in  Chapter  VI. 

NEUROSES  OF  THE  FACE 

Neuroses  of  the  face  which  distort  the  expression  or 
otherwise  impair  normal  function  are  anesthesia,  hyper- 
esthesia, paralysis,  hypertrophy,  atrophy,  leontiasis  ossea 
and  acromegaly,  the  two  latter  considered  elsewhere. 


170  SURGICAL   DISEASES   OF    THE   FACE 

Anesthesia  is  a  loss  of  sensation,  and  when  of  the  face 
it  is  caused  by  a  lesion  of  the  fifth  nerve,  usually  located 
within  the  cranial  cavity. 

Hyperesthesia  of  the  face  is  an  oversensitive  condition 
resulting  from  some  irritation  or  inflammation  of  the  fifth 
nerve,  or  it  may  be  due  to  inflammation  of  the  skin.  In 
neuralgia  there  is  usually  hyperesthesia  with  pain. 

Paralysis  of  the  muscles  of  the  face  is  due  to  a  lesion 
of  the  seventh  nerve,  when  the  muscles  of  the  entire  side  of 
the  face  droop  and  are  expressionless.  Saliva  trickles  from 
the  mouth.  This  condition  is  known  as  Bell's  palsy.  "When 
both  sides  of  the  face  are  involved  it  is  known  as  diplegia. 

Facial  spasms,  also  known  as  a  convulsive  tic,  are  tonic 
sjoasms  of  a  certain  muscle,  or  possibly  a  group  of  muscles, 
which  only  appear  during  wakeful  moments. 

Hypertrophy  of  the  face  is  usually  congenital  and  due 
to  some  perversion  of  the  trophic  nerves  during  early  devel- 
opment. 

Atrophy  of  one  side  of  the  face  is  seen  in  torticollis,  and 
is  a  result  of  withdrawal  of  nutrition,  no  doubt  caused  by 
the  tonic  spasm  of  the  vasomotor  nerves  of  the  affected 
side. 

Ristis  sardonicus  is  a  contraction  of  the  risorius  mus- 
cles, which  have  their  origin  from  the  fascia  over  the  masse- 
ter  muscles  and  are  inserted  in  the  skin  at  the  angle  of  the 
mouth.  A  spasm  of  these  muscles  produces  a  characteristic 
grin  and  is  seen  in  strychnia  poisoning. 


CHAPTER  XVII 


GENERAL   BONE    DISEASES 


Classification  of  the  Inflammatory  Diseases  of  Bones.— 

Diseases  of  the  bones  fall  into  two  general  classes :  Osteo- 
myelitis—  (1)  General  infective,  (2)  acute  circumscribed, 
(3)  chronic  circumscribed,  (4)  acute  diffused,  (5)  chronic 
diffused;  and  Periostitis — (1)  Acute  infective,  or  suppura- 
tive, (2)  post  febrile  (following  typhoid,  pneumonia,  scar- 
latina, etc.) 

OSTEOMYELITIS 

1.  General  Infective  Osteomyelitis.— This  condition  con- 
stitutes the  vast  majority  of  bone  diseases.  The  acute  form 
is  less  common  than  the  chronic,  and  twice  as  many  males 
as  females  are  affected.  The  disease  occurs  four  times  as 
frequently  among  children  as  among  adults.  It  is  rare  in 
mature  bones.  As  to  location,  bones  are  affected  in  the 
following  order:  the  maxilla,  the  mandible,  either  end  of 
the  tibia,  lower  end  of  the  femur,  upper  end  of  the  humerus, 
the  ulna,  fibula,  radius,  metacarpal  and  metatarsal  pha- 
langes. Other  bones  are  rarely  affected.  The  hacterium 
producing  the  majority  of  the  cases  is  the  Staphylococcus 
aureus,  although  other  organisms  may  be  the  cause.  The 
course  is  determined  by  the  variety  of  bacterium  producing 
the  disease.  Streptococcus  produces  the  acute,  rapidly 
developing  disease,  with  chill,  high  temperature,  stupor 
and,  in  some  instances,  death  in  a  few  days.  Staphylococ- 
cus aureus  is  the  germ  present  in  the  low-grade  destruc- 

171 


172  GENERAL    BONE    DISEASES 

tions  extending  over  months  or  years.  The  author  has  had 
several  cases  without  symptoms  except  jDain — one  for  fif- 
teen years,  one  for  twelve,  one  for  eight  and  one  for  seven, 
and  others  from  three  to  five  years. 

Predisposing  factors  are  general  impairment  of  health 
from  any  cause,  and  exposure  to  which  has  been  added  an 
injury  of  the  bone.  Growing  bones  are  also  a  factor.  In- 
fection occurs  by  inoculation  from  abrasions  in  the  mouth 
or  nose,  or  from  skin  pustules  and  from  eczema  or  other 
skin  lesions.  Staphylococci  may  pass  through  the  blood 
current  via  the  nutrient  artery  and  set  up  the  disease  imme- 
diately or  may  remain  latent  for  months. 

Pathological  changes  that  occur  are  much  the  same, 
whether  the  course  is  acute  or  chronic.  The  bone  marrow 
is  the  primary  seat  of  the  infection,  the  usual  point  being 
the  ossifying  center  where  the  nutrient  artery  terminates 
and  spreads  out  in  the  form  of  loops.  This  being  the  weak- 
est point  of  a  growing  bone,  it  is  first  injured.  Congestion, 
which  may  be  very  slight,  is  the  nidus  or  culture  medium 
for  the  development  of  the  colony  of  bacteria.  The  invaded 
area,  first  red,  soon  changes  to  a  gray  and  yellow  or  may 
become  greenish,  due  to  the  hemolytic  action  of  bacteria. 
The  cancellous  nature  of  the  bone  may  permit  extensive 
involvement  of  the  medullary  canal  before  suppuration  oc- 
curs. Solution  of  the  soft  tissues  of  the  marrow  first  oc- 
curs, the  trabecula  later  breaking  down,  and  cavities  are 
formed. 

The  cortex  is  invaded  rather  early  by  extension  through 
the  Haversian  canals,  the  inflammatory  exudate  escapes 
through  it,  and  the  periosteum  may  be  lifted  for  a  consid- 
erable space.  Abscess,  subperiosteal,  is  formed,  which  may 
break  through  the  tissues  and  skin.  Toxemia  and  death 
may  ensue  if  prompt  incision  is  not  made.  Spontaneous 
fracture  may  occur  as  the  result  of  destruction  of  the  cor- 
tex or  at  the  epiphysis. 

Sequestrum  is  formed  as  the  pus  lifts  the  periosteum 


OSTEOMYELITIS  173 

from  the  body  of  the  bone  or  shaft,  and  the  periosteum, 
because  of  its  regenerating-  function,  proceeds  to  build  up 
new  bone  and  an  involucrum  is  formed.  Regeneration  of 
bone  is  from  the  periosteum  and  endosteum,  principally 
the  former.  Bone  has  little  if  any  power  to  repair  itself. 
Destruction  of  bone  is  irregular  and  rejDair  is  also  irregu- 
lar and  coextensive  with  the  preservation  of  the  periosteum 
and  endosteum.  When  these  membranes  have  been  de- 
stroyed there  can  be  no  regeneration. 

2.  Acute  Circumscribed  Osteomyelitis.— This  is  a  very 
common  form,  and  is  sometimes  called  bone  furuncle.  The 
symptoms  are  localized  jiain  with  tenderness  later.  There 
is  no  swelling  unless  the  periosteum  is  secondarily  involved. 
Pain  is  most  severe  at  night,  especially  in  syphilitics.  The 
joint  is  usually  freely  movable.  The  condition  is  usually 
located  at  an  ossifying  center,  such  as  the  lower  end  of  the 
tibia  or  the  femur.  The  course  is  rather  subacute,  with 
acute  exacerbations,  when  the  pain  is  very  severe  and  when 
the  patient  may  lose  weight.  Diagnosis  is  confirmed  by  the 
use  of  the  X-ray,  which  will  show  a  light  area  near  the 
epiphyseal  line. 

3.  Chronic  Circumscribed  Osteomyelitis.— Chronic  cir- 
cumscribed osteomyelitis  may  continue  from  the  acute 
form,  becoming  latent  with  recurring  attacks  of  pain.  There 
may  be  nothing  more  than  a  displacement  of  organic  struc- 
tures, with  pus  and  some  destruction  of  the  trabecula.  A 
distinct  cavity  may  not  form  for  several  years,  as  was  ob- 
served by  the  writer  in  three  cases.  In  other  cases  a  dis- 
tinct abscess  will  be  found  which  may  extend  throughout 
the  shaft  and  a  sequestrum  is  usually  found.  Symptoms 
will  include  pain  and  loss  of  weight.  Other  local  symptoms, 
such  as  swelling  and  redness,  are  absent,  only  occurring 
when  the  cortex  is  perforated  and  the  pus  escapes  under- 
neath the  periosteum. 

4.  Acute  Diffused  Osteomyelitis.— Acute  diffused  osteo- 
myelitis has  a  sudden  onset  with  chills  and  high  tempera- 


174  GENERAL    BONE    DISEASES 

ture.  Prostration  and  stupor  are  marked.  This  is  fol- 
lowed by  coma  and  death  unless  the  source  of  the  toxemia 
is  destroyed.  Pain  is  severe  and  confined  to  the  bone  in- 
volved. Extension  to  the  periosteum  produces  swelling, 
redness,  a  glazed  skin  and  spontaneous  eruption.  The  ab- 
scess may  be  large,  since  the  pus  may  burrow  throughout 
an  extremity  in  a  week  or  so  when  diagnosis  and  operation 
are  not  made. 

The  bacterium  causing  the  acute  form  is  streptococcus. 
The  pathological  changes  in  the  bone  are  usually  extensive. 
Multiijle  abscesses  are  found  in  some  bones.  In  others  the 
entire  shaft  is  involved,  extending  to  the  epiphysis.  In 
streptococcic  infection  it  is  not  unusual  for  the  disease  to 
extend  into  the  joint  cavity.  When  extensive  destruction 
occurs,  troublesome  sinuses  or  deformity  are  not  infre- 
quent results.  Recovery  should  result  when  prompt  in- 
cision, drainage  and  disinfection  are  carried  out.  Se- 
questrotomy  and  even  amputation  are  in  many  cases  de- 
manded. 

5.  Chronic  Diffused  Osteomyelitis.— Chronic  diffused 
osteomyelitis  resembles  the  tuberculous  and  syphilitic 
forms.  Indeed,  it  is  a  question  whether  it  is  not  usually 
specific  rather  than  true  osteomyelitis. 

Differential  Symptoms.— In  all  forms  of  osteomyelitis 
there  is  no  swelling  unless  the  periosteum  is  secondarily 
involved;  pain  is  localized,  but  may  radiate  to  other  parts 
of  the  same  extremity;  tenderness  of  the  hone  is  generally 
found  to  be  more  marked  at  the  epiphyseal  line;  and  tem- 
perature ranges  in  proportion  to  the  toxemia,  which  de- 
pends upon  bacterial  activity  and  increases  with  pain  and 
persists  through  abscess  formation,  but  drops,  as  a  rule, 
when  the  abscess  is  opened.  Periosteal  involvement  pro- 
duces swelling  or  edema  which  pits  on  pressure,  redness  of 
the  skin  resembling  erysipelas  or  extension  under  the  skin 
resembling  cellulitis.  Rheumatism  is  the  one  condition  con- 
founded with  this  disease  more  frequently  than  any  other. 


OSTEOMYELITIS  175 

Localized  pain  in  a  bone  or  joint  is  seldom,  if  ever,  rheuma- 
tism.   Tlie  X-ray  should  always  be  used  when  available. 

Local  Complications.— The  local  complications  are  ar- 
thritis by  extension  into  the  joint,  and  fracture  (pathologi- 
cal) due  to  destruction  of  bone  and  very  slight  violence. 

General  Complications.— Pyemia  is  a  general  complica- 
tion in  which  secondary  foci  may  be  found  in  other  bones. 
Endocarditis,  infective  embolism,  metastasis,  etc.,  are  not 
uncommon.  During  active  attacks  the  patient  is  dull,  list- 
less, restless  and  may  become  delirious.  Typhoid  condition 
(so-called)  is  present  and  this  disease  is  often  confounded 
with  osteomyelitis.  Scarlatina  is  also  mistaken  for  osteo- 
myelitis, since  in  some  cases  there  is  an  erythema,  with 
scanty  urine  containing  blood  and  albumen. 

Differential  Diagnosis. — Differentiation  must  be  made 
from  superficial  inflammation,  erysipelas,  cellulitis,  primary 
periostitis,  rheumatism,  and  arthritis  of  various  forms. 

Prognosis.— The  prognosis  is  good  when  a  diagnosis  is 
made  early  and  proper  drainage,  disinfection,  etc.,  are  car- 
ried out  promptly.  Procrastination  means  death  or  exten- 
sive destruction  in  the  acute  cases  and,  in  the  chronic  cases, 
disability  due  to  destruction  of  bone. 

Treatment.— 1.  Drainage  may  be  made  by  drilling,  fol- 
lowed by  chiseling  to  make  an  opening  large  enough  to 
reach  the  seat  of  the  disease. 

2.  Curettement  should  be  done  cautiously,  yet  with  suf- 
ficient thoroughness  to  remove  all  detritus,  jdus  or  seques- 
trum, and  until  red  or  bleeding  bone  is  reached. 

3.  Tincture  of  iodin  (U.  S.  P.)  should  now  be  poured 
into  the  cavity  and  permitted  to  stand  there  for  from  three 
to  five  minutes.  When  a  cavity  is  deep  a  syringe  long 
enough  to  reach  the  bottom  of  it  should  be  used.  Gauze 
may  be  saturated  with  tincture  of  iodin  and  packed  into 
the  cavity  when  it  is  found  more  convenient.  The  iodin 
will  infiltrate  into  the  cancellous  bone  and  reach  out  and 
destroy  germs  in  the  zone  of  invasion  far  beyond  the  extent 


176  GENERAL   BONE    DISEASES 

of  curettement.  lodin  poisoning  need  not  be  feared,  as  tlie 
author  lias  used  an  ounce  without  a  toxic  symptom.  Ex- 
cessive amounts  of  iodin  placed  in  a  cavity  should  be 
mopped  out  after  three  or  four  minutes. 

4.  Permit  the  cavity  to  well  full  of  blood,  and  seal.  If, 
however,  hemorrhage  is  excessive,  it  may  be  necessary  to 
pack  the  cavity  for  twenty-four  hours,  after  which  time 
packing  should  be  removed.  The  wound  will  usually  well 
full  of  blood  and  it  should  then  be  sealed  as  before. 

5.  Skin  wounds  should  be  closed  with  catgut  or  silk- 
worm gut.  When  there  is  doubt  as  to  the  thoroughness 
of  the  disinfection,  etc.,  drainage  may  be  left  through  the 
skin  only  to  guarantee  against  possible  infection  of  blood- 
clot. 

6.  Second  dressing  is  used  only  when  symptoms  of 
return  of  pain  or  temperature  demand  it,  which  may  not 
be  for  a  week. 

Blood-clot  organization  is  typified  in  the  repair  of  the 
maxillary  process  after  the  extraction  of  teeth.  Here  we 
may  extract  many  teeth,  leaving  holes  of  considerable  size 
which  are  immediately  filled  in  with  blood,  and  even  the 
patient  never  hear  of  it  again.  Why  not  larger  cavities? 
As  must  be  well  known  to  all  observing  surgeons,  no  opera- 
tion is  performed  without  there  being  more  or  less  blood- 
clot  interposed  between  the  flaps  and  portions  of  the  area 
included  in  the  operation  after  adjustment  of  sutures.  This 
blood-clot  is  nature's  method  of  filling  in  cavities  and  va- 
cant spaces  which  must  necessarily  exist.  To  be  sure,  these 
cavities  vary  in  size  in  different  operations.  They  disap- 
pear and  the  wound  entirely  heals  without  the  surgeon's 
being  cognizant  of  their  existence  in  all  sterile  wounds. 
This  is  what  surgeons  choose  to  call  blood-clot  organiza- 
tion. 

The  method  of  repair  is  about  as  follows :  The  blood- 
clot  which  fills  in  the  cavity  serves  as  a  trellis  work  into 
which  the  leucocytes  begin  to  pour  from  the  healthy  blood 


PERIOSTITIS  177 

vessels  immediately  after  all  operations  and  injuries.  In 
the  course  of  a  few  days  the  blood-clot  has  been  entirely 
displaced  by  the  scavenger  leucocytes  and  the  cells  thrown 
out  along  the  margin  of  the  wound  for  the  purpose  of  re- 
construction and  repair.  The  reparative  cells  eventually 
take  the  place  of  the  leucocytes  and  become  thoroughly 
organized,  and  the  cavities  are  thus  filled  in  with  the  new- 
formed  tissue  or  scar  tissue. 

The  practice  of  packing  sterile  cavities  with  gauze  at 
every  dressing  is,  in  the  author's  opinion,  wrong,  since  it 
breaks  down  and  destroys  blood-clots  and  valuable  plastic 
material  thrown  out  by  nature  to  rebuild  damaged  tissues. 
If  gauze  is  pushed  into  the  center  of  the  bone  cavity  daily, 
months  will  be  required  for  repair  of  such  a  large  opening 
in  the  center  of  the  bone.  If  the  work  has  been  complete, 
all  active  symptoms  will  have  disappeared  and  the  conduct 
of  the  wound  will  be  the  same  as  that  of  wounds  after  oper- 
ations in  soft  parts.  This  is  not  a  theoretical  proposition, 
but  it  has  been  demonstrated  in  practice  in  a  sufficient  num- 
ber of  cases  to  claim  for  it  a  place  in  surgical  practice. 

PERIOSTITIS 

Classification  (Peters),— Cases  of  periostitis  fall  into 
two  classes:  (1)  Suppurative  disease,  a  sequel  or  terminal 
result  of  acute  osteomyelitis,  or  diffused  periostitis;  (2) 
post-fehrile  periostitis  following  typhoid  fever,  pneumonia, 
scarlatina,  measles,  etc. 

1.  Acute  Suppuration.— Some  authorities  doubt  the  ex- 
istence of  an  acute  suppurative  periostitis  as  a  primary  con- 
dition, but  say  that  it  is  a  cortical  osteitis  or  is  secondary 
to  an  acute  osteomyelitis.  The  causes  may  be  predispos- 
ing, such  as  a  weakened  resistance  from  any  cause,  and  a 
slight  contusion;  and  exciting,  such  as  the  presence  of  some 
bacterium,  as  streptococcus  (acute  form)  or  staphylococcus 
(in  subacute  form),  to  which  is  usually  added  an  injury. 


178  GENERAL   BONE    DISEASES 

Pathology. — The  injury  results  in  congestion  of  the  peri- 
osteum, the  stasis  of  blood  being  a  nidus  for  implantation 
and  growth  of  the  bacteria.  The  disease  is  usually  circum- 
scribed. The  fluid  accumulation  is  at  first  serous  and  only 
becomes  purulent  when  sufficient  time  has  elapsed  for  pha- 
gocytosis to  occur.  Extensive  accumulations  of  serum  may 
form  in  two  or  three  days.  The  symptoms  are  swelling, 
which  is  prominent  from  the  beginning;  edema  which  pits 
on  pressure,  which  is  almost  pathognomonic  of  periostitis 
when  associated  with  local  acute  symptoms;  and,  in  acute 
forms,  chill,  high  temperature,  frequent  pulse,  red  and 
glossy  skin,  severe  pain  during  the  early  stage,  poor  appe- 
tite, sleeplessness,  emaciation  and  general  loss  of  vital 
forces,  and  bogginess  and  fluctuation,  which  will  be  ob- 
served as  liquid  accumulation  increases. 

Treatment. — The  following  measures  are  to  be  adopted : 
(1)  Incision  down  to  the  bone,  opening  to  be  long  enough 
to  guarantee  free  drainage;  (2)  disinfection  with  tincture 
of  iodin  after  the  wound  has  been  thoroughly  cleansed;  (3) 
closure  of  the  wound  in  all  acute  cases  to  permit  the  peri- 
osteum to  adhere  to  the  bone,  which  can  be  expected  when 
the  operation  is  complete  and  the  wound  sterile. 

2.  Post-febrile  Periostitis.— Typhoid  and  other  post- 
febrile conditions  not  uncommonly  develop  as  sequels  to 
this  disease  during  reduced  resistance.  Cidtures  of  the 
product  show  pure  typhoid  bacillus  when  it  follows  this 
disease.  Keene  reports  thirty-seven  cases.  Treatment  con- 
sists in  incision,  disinfection,  and  drainage  through  the 
skin.  Eepair  is  usually  prompt,  without  exfoliation,  un- 
less there  has  been  great  delay  in  operating.  Other  post- 
operative periostitis  or  osteomyelitis  requires  similar  treat- 
ment. Tuberculous  and  syphilitic  diseases  of  the  bone  and 
periosteum  are  to  receive  special  consideration  under  those 
heads. 


CHAPTER  XVIII 


DISEASES    OF    THE    MANDIBLE 


After  the  student  has  made  a  study  of  the  preceding 
chapter  and  has  mastered  the  subject  of  bone  diseases  in 
general,  he  will  have  little  difficulty  in  understanding  dis- 
eases of  the  bones  of  the  face  as  they  are  seen  in  dental 
practice. 

The  bones  of  the  face  which  may  be  diseased,  and,  there- 
fore, of  special  interest  to  the  dentist,  are  the  mandible, 
the  maxilla,  the  palatine,  the  ethmoid,  and  the  pterygoid 
plates  of  the  sphenoid. 

Classification. — The  diseases  may  be  classified  etiologi- 
cally  as  follows :  1.  Alveolar  necrosis.  2.  Periostitis  of 
the  body.  3.  Osteomyelitis.  4.  Chemical  necrosis— a.  phos- 
phorus ;  b.  mercury ;  c.  arsenic.  5.  Exanthematous — a. 
scarlatina ;  b.  measles ;  c.  typhoid ;  d.  pneumonia. 

Death  of  the  bones  of  the  face  may  occur  as  a  necrosis 
or  death  en  masse,  and  a  caries  or  a-  molecular  disintegra- 
tion of  the  bone.  These  terms  are  intimately  associated, 
for  caries  or  molecular  disintegration  is  present  at  the 
periphery  of  the  diseased  area  before  the  sequestrum  can 
be  cast  away  from  the  healthy  bone,  and  when  the  seques- 
trum is  in  very  deep  tissue,  as  the  body  of  a  vertebrae,  a 
large  piece  of  bone  may  dissolve  by  a  carious  process.  In 
fact,  these  terms  apply  to  incidents  in  the  history  of  a  dis- 
ease when  it  is  considered  etiologically  and  not  to  distinct 
diseases.  However,  much  respect  must  be  given  them  be- 
cause they  have  been  reverenced  since  the  beginning  of 
medicine. 

179 


180  DISEASES    OF   THE   MANDIBLE 

Faulty  Use  of  Hypodermic  Syringe  as  an  Etiological 
Factor.— In  the  author's  experience  the  injudicious  use  of 
the  hypodermic  syringe  to  jDroduce  local  anesthesia  before 
extraction  is  a  most  fruitful  source  of  acute  periostitis, 
resulting  in  exfoliation  of  a  portion  of  the  alveolus.  Death 
of  bone  may  result  by  infection  from  the  needle ;  or  it  may 
follow  the  mechanical  destruction  of  the  periosteum  caused 
by  the  needle's  being  pushed  into  the  membrane,  the  anes- 
thetic being  forced  into  the  tissues  destroying  its  vitality; 
or  the  needle  may  be  forced  between  the  bone  and  the  peri- 
osteum, lifting  the  latter,  thus  causing  death  of  bone. 


ALVEOLAR  NECROSIS, 

A  most  common  condition  and  one  frequently  seen  by 
the  dentist  is  simple  exfoliation  of  the  alveolar  process,  as 
a  result  of  suppurative  conditions  about  the  teeth,  such  as 
alveolar  abscess,  traumatisms,  extractions,  ulcerative  stom- 
atitis, or  other  gingival  destructions  or  infections.  As  a 
rule,  such  minor  conditions  are  cared  for  by  the  dentist.  A 
portion  of  the  bone  representing  the  process  over  a  tooth 
is  removed,  and  repair  follows  in  a  few  days. 

Occasionally  the  disease  runs  a  more  grave  course, 
larger  areas  of  bone  are  involved,  suppuration  is  continued, 
and  a  sinus,  persistent  in  its  nature,  is  established.  These 
conditions  run  a  very  acute  course  and  are  caused  by  the 
introduction  of  streptococcus  or  some  other  active  bac- 
terium into  the  tissues. 

Symptoms.— The  most  important  symptoms  are  persis- 
tent pain  and  swelling  that  pits  on  pressure,  known  as 
edema,  tenderness,  rigors  and  possibly  chills,  followed  with 
slight  fever.  All  swelling  of  the  process,  however,  must 
not  be  considered  a  forerunner  of  serious  necrosis.  Indeed, 
such  a  result  would  be  the  exception. 

Diagnosis. — The  diagnosis  is  very  important  since  it  is 


ALVEOLAR   NECROSIS  181 

upon  the  early  and  proper  management  of  such  a  case  that 
the  subsequent  history  depends. 

Prognosis. — The  prognosis  is  very  good  if  the  trouble 
is  recognized  and  incised  before  pus  formation.  Even  after 
pus  formation,  recovery  may  take  place  if  delay  has  not 
been  too  great. 

Treatment.— The  treatment  includes  the  removal  of  the 
cause.    If  stomatitis,  use  local  antiseptics  and  control  infec- 


FiG.  34. — Periostitis   of   Mandible.     Showing   area  of  exfoliation   of  bone 

from  internal  surface. 

tions.  Disinfect  the  ulcer  early  with  tincture  of  iodin,  with 
the  hope  that  sequestration  will  not  occur.  Early  curette- 
ment  of  the  bone  and  disinfection,  in  cases  where  the  peri- 
osteum is  involved,  may  also  induce  repair  without  exfolia- 
tion. When  the  latter  is  evident,  time  should  be  given  for 
the  line  of  demarcation  to  be  established  before  extensive 
operations  are  performed.  It  should  be  remembered,  how- 
ever, that  the  great  majority  of  cases  are  averted  by  early 
incision  and  disinfection. 

Traumatisms.— Injuries  of  the  alveolus,  other  than  those 
from  tooth  extractions,  may  come  from  blows  or  be  asso- 
ciated with  fractures.  Here  we  usually  have  infection,  peri- 
ostitis and  exfoliation  of  a  portion  of  the  external  table  of 
the  bone,  as  the  accompanying  case  shows. 

A  boy,  aged  twelve  years,  received  a  blow  over  the  right 
side  of  the  mandible  with   sufficient  force  to  loosen  two 


182  DISEASES    OF   THE   MANDIBLE 

teeth.  Shortly  afterward  the  wound  became  infected,  and 
during  the  course  of  several  weeks  extensive  swelling,  pain 
and  constitutional  symptoms  developed.  At  the  end  of  two 
months  an  examination  showed  that  the  lingual  alveolar 
margin  for  more  than  an  inch  was  exposed  and  imbedded 
in  pus  and  surrounded  by  granulation  tissue.  At  this  time, 
under  local  anesthetic,  the  bone,  as  shown  in  Fig.  34,  was 
removed.  Other  smaller  pieces  exfoliated  later.  The  teeth 
were,  however,  all  preserved  except  the  second  bicuspid. 

PERIOSTITIS  OF  THE  BODY  OF  THE  MANDIBLE 

This  variety  of  disease  usually  follows  infection  from 
the  gingival  margin,  extending  along  the  bone  under  the 

periosteum.  Some  of  these 
cases  are  most  persistent, 
and  the  dentist  or  family 
physician  may  carry  out  the 
usual  methods  of  treat- 
ment, such  as  injections 
with  supposedly  valuable 
germicidal  remedies,  with- 
FiG.  35.-PERIOSTITIS.    Shaded  portion  ^   ^   repair.     In   such   cases 

showmgarea  of  denuded  bone.  ^ 

a  radical  operation  is  neces- 
saiy  before  repair  can  be  effected. 

Treatment.— ^lien  the  existence  of  a  periostitis  is  fully 
determined,  a  free  incision  should  be  made  down  to  the 
bone,  for  just  as  soon  as  the  colony  of  bacteria  that  is  caus- 
ing the  trouble  is  reached  and  disconcerted,  their  activity 
ceases  and  repair  begins.  AMien,  however,  myriads  of  bac- 
teria are  permitted  to  go  on  and  multiply  and  destroy  liv- 
ing cells,  destruction  is  relatively  great.  The  early  treat- 
ment would  appear  to  be  applications  of  iodin  and  heat  or 
ice,  to  be  followed  by  incision  in  two  or  three  days  if  no 
improvement  is  obtained  by  these  remedies. 

Illustrative  Case.— A  boy,  aged  twelve  years,  had  a  sinus 


OSTEOMYELITIS    OF    THE    BODY 


183 


from  the  right  side  of  the  mandible  for  several  months, 
which  failed  to  repair  even  after  operations  and  medica- 
tion. A  free  incision  from  the  facial  artery  to  the  sym- 
physis, baring  the  bone,  as  shown  in  the  drawing,  was  made. 
At  some  points  along  the  under  surfaces  of  the  body  of  the 
bone  little  vitality  was  shown, 
and  the  surface  was  chiseled 
away  until  blood  oozed  from 
the  entire  surface.  The  cavity 
was  then  thoroughly  disin- 
fected with  iodin.  The  peri- 
osteum was  first  sutured  with 
fine  catgut.  The  skin  was 
closed  over  this  with  silkworm 
gut.  Nothing  but  silkworm 
gut  drainage  was  used.     The 

wound  healed  as  promptly  as  occurs  following  clean  wounds 
without  a  drop  of  pus  or  a  symptom.    (Figs.  35  and  36.) 


Fig.  36. — Periostitis.  Photograph 
ten  days  after  operation  showing  im- 
mediate repair  without  symptoms. 


OSTEOMYELITIS  OF  THE  BODY  OF  THE  MANDIBLE 

A  more  severe  form  of  acute  periostitis  and  other  de- 
structive diseases  of  the  bone  are  dependent  upon  causes 
independent  of  the  teeth  and  only  secondarily  involving 
them.  The  usual  causes  are  blows  and  injuries  associated 
with  extractions,  such  as  fracture  of  the  process  opening 
up  a  deep  area  for  infection. 

Causes.— These  conditions  may  develop  as  a  periostitis 
or,  from  the  surface  of  the  bone,  as  an  osteomyelitis,  be- 
ginning in  the  central  canal,  the  infection  gaining  entrance 
through  the  root  of  a  tooth.  Injudicious  use  of  arsenic  in 
the  treatment  of  root  canals  is  unquestionably  a  cause  of 
extensive  necrosis.  Several  cases  from  this  cause  have  been 
under  treatment. 

Illustrative  Cases.— (1)  A  patient,  a  man  aged  fifty,  with 
infection  of  the  mandible,  had  lost  all  of  his  lower  teeth  but 


184 


DISEASES    OF   THE   MANDIBLE 


three,  and  the  cavity  included  practically  all  of  the  mandi- 
ble on  its  external  surface,  the  bone  being  bare  throughout. 
The  alveolar  process,  on  its  external  margin,  including  the 
cavities  left  by  the  extracted  teeth,  stood  out  perfectly  nude 
in  the  floor  of  the  mouth.  It  had  required  just  a  month  for 
the  case  to  advance  to  the  condition  described.    The  oper- 


FiG.  37. — Alveolar  Process  in  Osteomyelitis,    a.  Internal  alveolus;  b.  exter- 
nal alveolus;  c.  external  gingiva;  d.  internal  gingiva;  e.  lip. 

ation  included  a  complete  removal  of  the  external  half  of 
the  mandible  from  the  second  molar  on  the  right  side  to 
the  second  bicuspid  on  the  left,  through  the  roots  of  the 
teeth  and  to  the  external  inferior  margin  of  the  bone.  This 
left  the  internal  alveolar  plate  intact  throughout  with  the 
periosteum  undisturbed.  The  cavity  was  mopped  out  with 
pure  tincture  of  iodin.  The  usual  method  of  procedure 
would  doubtless  have  been  to  pack  the  entire  cavity,  with 
the  hope  that  the  bone  would  heal  by  being  granulated  over 


OSTEOMYELITIS    OF    THE    BODY 


185 


from  later  approximation  of  the  external  periosteum.  It 
was  decided,  however,  that  such  an  extensive  cavity  should 
be  immediately  obliterated.  Dependent  drainage  was  abso- 
lutely necessary  if  this  were  to  be  accomplished ;  hence,  an 
incision  was  made  from  the  lowest  point  of  the  cavity  in  the 
median  line  through  the  skin  under  the  chin  large  enough 


Fig. 


38. — Alveolar  Process  in  Osteomyelitis,     a.  Internal  alveolus; 
c.  external  gingiva;  d.  internal  gingiva;  e.  lip. 


to  admit  a  rubber  drain  the  size  of  a  lead  pencil.  The  next 
step  was  to  stitch  together  with  catgut  the  labial  and  buccal 
gingival  margins,  thus  closing  off  the  field  of  operation 
entirely  from  the  oral  cavity.    (Figs.  37  and  38.) 

Post-operative  History. — The  two  gingival  margins 
completely  united  and  not  a  drop  of  pus  was  ever  found  in 
the  oral  cavity.  The  drainage  established  from  below  was 
quite  sufficient  to  carry  off  the  small  quantity  of  reparative 


186 


DISEASES    OF   THE   MANDIBLE 


lympli  and  detritus  and  the  patient  was  practically  well  in 
ten  days  after  his  operation. 

This  method  of  obliterating  cavities  is  applicable  regard- 
less of  the  extent  of  operation,  whether  of  one  or  many 
teeth,  or  of  the  mandible  or  the  maxilla,  or  whether  of  the 
alveolus  or  of  half  of  the  body.  It  is  well  in  such  cases  to 
disinfect  the  cavity  and  close  it  off  as  nearly  as  possible.  In 
both  instances  iodin  should  be  used  to  disinfect  and  an 
effort  should  be  made  to  obliterate  the  cavity  in  order  to 


Fig.  39. — Osteomyelitis  of  the  Mandible. 

preserve  blood-clot  organization.  In  neither  of  these  cases 
should  the  wound  be  packed,  because  the  blood-clot  of  re- 
pair will  be  destroyed.  Besides,  the  soft  tissues  will  be 
pushed  away  from  the  bone  and,  further,  death  of  bone 
must  be  expected. 

It  is  not  advisable,  however,  to  establish  drainage  as  in 
this  case,  except  in  very  extensive  destructions.  In  view  of 
the  almost  certain  possibility  of  a  spontaneous  opening  in 
severe  cases,  an  incision  made  where  the  scar  will  show  the 
least  is  preferable  to  the  establishment  of  an  opening  where 
the  scar  may  be  dimpled  and  on  the  external  surface  of  the 
bone. 


CHEMICAL    NECROSIS  187 

(2)  Figure  39  shows  a  girl,  aged  five  years,  who  had  ex- 
tensive enlargement  over  the  left  angle  of  the  mandible. 
There  was  a  sinns  three  inches  below  this  bone  just  at  the 
posterior  margin  of  the  platysma  leading  up  to  the  angle. 
Several  sinuses  also  terminated  in  the  mouth.  The  bone  was 
denuded  at  several  points.  This  condition  was  preceded  by  a 
history  of  abscess  formation,  pain,  and  spontaneous  erup- 
tion. The  bone  was  denuded  of  periosteum  along  the  ex- 
ternal surface  of  the  ramus  and  the  greater  part  of  the  bone 
was  removed,  only  a  thin  table  upon  the  internal  surface 
remaining.  Operation  consisted  in  chiseling  away  the  en- 
tire process  down  to  the  central  canal  and  removing  at 
least  the  upper  half  of  the  bone  at  the  angle.  The  cav- 
ity was  not  packed,  but  the  external  periosteum  w^as  al- 
lowed to  collapse  upon  the  bone  with  the  hope  that  it  would 
become  adherent.     Repair  followed  in  a  few  weeks. 

CHEMICAL  NECROSIS 

Chemical  necrosis  includes  all  those  destructions  of 
bone  due  to  the  corrosive  action  of  drugs,  either  by  inhala- 
tion or  by  their  internal  administration  or  local  application. 
Drugs  which  have  caused  death  of  bone  are  phosphorus, 
mercury  and  arsenic. 

Phosphorus  Necrosis 

Phosphorus  necrosis  is  usually  of  the  alveolar  process 
and  more  frequently  of  the  mandible  than  of  the  maxilla. 
It  is  found  in  the  younger  workers  in  match  factories,  and 
is  due  to  the  corrosive  action  of  the  fumes  of  phosphorus 
upon  the  bone  or  its  membrane.  It  was  thought  by  some 
that  it  acted  through  the  system  like  mercury,  but  all  are 
now  of  the  opinion  that  its  action  is  entirely  local.  The  cor- 
rosive action  upon  the  periosteum  and  bone  structures 
gains  access  either  through  an  abrasion  about  a  tooth  or 
through  an  exposed  pulp  or  open  root  canal,  probably  the 
latter. 


188  DISEASES    OP    THE    MANDIBLE 

The  first  symptom  is  an  ache,  which  gradually  increases 
in  severity  until  the  pain  becomes  excruciating.  The  gums 
swell  and  bleed  at  the  gingival  margin.  Swelling  increases 
and  the  gums  ulcerate  and  a  condition  of  pyorrhea  alveo- 
laris  is  developed.  Fistulous  openings  form  through  the 
mucous  membrane  and  not  infrequently  through  the  skin. 
The  sequestrum  is  rapidly  separated  as  the  extent  of  the 
disease  is  defined,  and  involucrum  rapidly  forms,  producing 
a  permanent  hard  enlargement  throughout  the  course  of  the 
disease.  One  very  prominent  and  early  symptom  is  a  char- 
acteristic fetor  of  the  breath. 

The  disease  does  not  develop  except  where  yellow  phos- 
phorus is  used.  In  Denmark,  where  this  variety  of  the  ele- 
ment was  superseded  twenty  years  ago  by  sesquisulphid 
of  phosphorus,  a  case  of  phosphorus  necrosis  has  not  been 
seen  since. 

Prognosis  and  treatment  are  the  same  as  for  other 
forms  of  necrosis. 

Phosphorus  necrosis  of  the  maxilla  is  rare  and  when  it 
does  develop  is  more  amenable  to  early  treatment  because 
of  the  advantage  in  drainage.  Otherwise,  the  treatment 
does  not  differ  from  disease  of  the  mandible. 

Meecueial  Neceosis  % 

Mercurial  necrosis  is  practically  unknown  to  the  mod- 
ern practitioner  of  medicine  or  dentistry  because  of  a  more 
judicious  use  of  this  drug  in  recent  years.  In  this  disease 
destruction  of  tissue  is  extensive.  It  begins  in  the  gums 
with  a  bluish  tinge.  This  is  followed  by  ulceration  and  in- 
volvement of  the  alveolus  and  adjacent  oral  tissues.  The 
teeth  become  loose  and  are  removed  or  drop  out.  The  man- 
dible and  maxilla  are  destroyed.  Death  results  in  many  of 
the  cases.  Treatment  differs  little  from  that  for  other 
forms.  The  administration  of  large  doses  of  potassium 
iodid  is  thought  to  eliminate  the  mercury  from  the  system 
and  to  encourage  repair  and  eventual  recovery. 


CHEMICAL    NECROSIS 


189 


Aesenical  Necrosis 

Arsenical  necrosis  is  dependent  upon  the  too  free  use 
of  this  drug  by  the  dentist,  for  the  purpose  of  devitalizing 
a  tooth-pulp,  or  upon  the  imperfect  sealing  of  the  drug  in 
the  cavity.  It  is  most  common  in  children  because  the 
apical  foramina  are  larger  and  the  drug  is  more  likely  to 
reach  the  peridental  membrane,  and  from  there  come  in 
contact  with  the  bone.  The  dentist  should  carefully  ob- 
serve instructions  as  to  the  use  of  arsenic  for  fear  of  pro- 


FiG.  40. — Arsenic  Necrosis. 

ducing  necrosis,  since  the  drug,  when  it  comes  in  contact 
with  the  bone  on  the  side  of  a  tooth,  will  destroy  its  nutri- 
tion, and  result  in  death  of  the  process. 

Treatment  consists  in  the  application  of  a  chemical 
antidote — hydrated  sesquioxid  of  iron,  if  the  case  is  seen 
early,  but  when  the  destruction  is  well  defined  this  is  of  no 
value.  Extensive  necrosis  is  not  usual,  the  disease  being 
confined  to  the  bone  immediately  around  the  tooth.  The 
sequestrum  usually  separates,  and,  after  its  removal,  re- 
pair takes  place  and  no  important  ill  consequences  follow. 

Illustrative  Case  of  Arsenic  Necrosis.— In  May,  the  first 


190 


DISEASES    OF    THE    MANDIBLE 


lower  molar,  after  the  usual  treatment  to  devitalize  the 
nerve,  etc,  was  capped  with  gold.  One  month  later,  June 
2nd,  the  bone  began  to  swell  back  of  this  tooth.  An  abscess 
formed  and  was  incised  by  a  surgeon.  This  operation  was 
no  doubt  as  thorough  as  conditions  demanded  at  the  time. 


Fig.  41. — Schematic  Outline  of  Bone  Removed. 

July  6th,  two  other  abscesses  showed  themselves  along  the 
body  of  the  bone  and  at  the  symphysis,  and  were  incised 


Fig. 


Reproduction  on  Mandible  of  Bone  Destroyed. 


by  the  same  surgeon.  October  16th  there  were  several  dis- 
charging sinuses  through  the  skin  below  the  bone  and  sev- 
eral openings  into  the  mouth,  all  discharging  profusely. 
The  patient  lost  weight  and  was  suffering  with  constitu- 
tional sepsis.  A  radical  operation  was  advised.  Operation 
through  the  mouth  was  done  under  a  general  anesthetic. 


CHEMICAL    NECROSIS 


191 


Incisions  were  made  along  the  process  and  external  sulcus 
as  necessary  to  remove  the  sequestra.  The  teeth  that  were 
loose  were  removed.  The  cavity  from  which  the  bones  were 
removed  extended  throughout  the  length  of  the  bone,  as 
indicated  above.  Some  small  bones  were  removed  at  sub- 
sequent times  without  anesthetic.  The  patient  made  a  per- 
fect recovery  and  was  entirely  well  in  a  few  weeks.    There 


Fig.    43. — Suppurative    Periostitis    of    the    Mandible.     (Dr.    J.    Howard 

Crawford.) 

was  no  deformity  of  the  face.  With  a  partial  lower  plate, 
functional  usefulness  of  the  parts  was  practically  normal. 
(Figs.  40,  41,  42.) 

Illustrative  Case  of  Periostitis.— Figure  43  shows  ex- 
tensive suppuration  of  the  entire  alveolar  process  of  the 
mandible,  with  the  teeth  and  gum  practically  floating  in  pus, 
the  buccal  alveolar  process  being  bare  throughout. 

The  author  saw  the  case  thirty  days  after  the  onset  of 
the  trouble,  when  all  of  the  teeth  had  been  extracted.    Op- 


192  DISEASES    OF    THE    MANDIBLE 

eration  similar  to  the  one  described  in  the  preceding  case 
was  performed,  which  inclnded  the  removal  of  the  external 
half  of  the  mandible  and  all  of  the  teeth  throughout,  back  to 
the  lingual  plate  and  to  the  bottom  of  the  sockets.  The 
labial  and  lingual  gingival  margins  were  sutured  through- 
out with  thirty-day  catgut,  and  drainage  established  under- 
neath the  chin.  The  case  did  not,  however,  repair  so 
promptly  as  the  one  just  described,  due  no  doubt  to  the 
fact  that  there  was  likely  a  specific  element  to  contend  with. 
It,  however,  finally  repaired  without  any  further  operation, 
with  the  exception  of  the  removal  of  two  or  three  small 
sequestra. 

EXANTHEMATOUS  NECROSIS 

From  time  to  time  there  are  developed  as  sequelae  of 
certain  acute  diseases,  such  as  typhoid  fever,  scarlatina, 
measles  and  pneumonia,  inflammatory  destructions  of 
bones,  joints,  glands,  etc.  The  inflammation  begins  shortly 
after  cessation  of  fever  and  other  active  symptoms,  as  pain 
in  a  bone,  develoi^ing  rapidly  into  an  acute  osteitis  or  peri- 
ostitis. The  course  is  not  very  different  from  that  resulting 
from  streptococcic  infection,  except  that  it  is  less  acute. 
The  history  of  the  preceding  disease  and  the  local  symp- 
toms of  osteomyelitis  must  be  considered  in  making  a  diag- 
nosis. Treatment  is  not  different  from  that  already  out- 
lined. 


CHAPTER   XIX 

DISEASES   OF    THE    MAXILLA 

ACUTE  SUPPURATIVE  DISEASES 

Several  cases  of  acute  suppurative  disease  of  the  body 
of  the  maxilla  have  been  under  treatment.  In  three  recent 
cases  the  periosteum  was  lifted  from  the  bone  for  a  greater 
portion  of  the  external  surface.  The  development  in  two 
of  the  cases  was  rapid.  Another  patient  had  tuberculosis 
of  the  hip  at  the  time.  Treatment  consisted  in  making  a 
free  incision  to  the  cavity.  After  the  pus  escaped,  the 
cavity  was  thoroughly  disinfected  with  tincture  of  iodin. 
The  cavities  w^ere  not  packed.  The  bone  was  curetted  in 
two  of  the  cases.  No  symptoms  developed  in  any  of  them. 
The  wounds  repaired,  the  periosteum  readhered  to  the 
bone,  and  no  necrosis  followed. 

Such  prompt  repair  after  diseases  of  the  maxilla  is  de- 
pendent upon  favorable  drainage,  as  against  no  drainage 
from  the  mandible.  In  no  case  of  disease  of  the  maxilla 
should  the  skin  be  incised.  All  incisions  should  be  made 
within  the  mouth,  usually  through  the  highest  point  of  the 
sulcus. 

Complications  by  loss  of  portions  of  the  maxillary  bones 
are  deformity,  perforation  of  the  nasal  and  antral  cavities, 
leaving  permanent  fistulae,  antral  suppuration  and  nerve 
injuries.  Probably  the  most  troublesome  complication  is 
naso-oral  fistula.  In  several  cases  this  condition  resulted, 
and  a  second  plastic  operation  was  required. 

A.  A.  J.,  aged  fifty-eight  years,  went  to  a  dentist  for  the 

193 


194 


DISEASES    OF    THE    MAXILLA 


extraction  of  a  right  lateral  root,  which  was  very  small  and 
was  causing  but  little  inconvenience.  The  dentist  used  a 
local  anesthetic  with  the  usual  care,  taking  such  precautions 
as  sterilizing  his  instruments  and  the  tissues.  There  fol- 
lowed, however,  in  the  course  of  twenty- 
four  hours,  extensive  periostitis,  which 
resulted  in  the  complete  destruction  of 
the  processes,  including  one  tooth  before 
and  one  behind  the  extracted  tooth,  and 
extending  up  toward  the  anterior  nares 
about  three-quarters  of  an  inch.  The 
bone  separated,  and  the  line  of  demarca- 
tion having  been  formed,  the  seciuestrum 
was  removed  about  two  weeks  after  the 
trouble  began.  The  cavity  was  freely 
curetted  and  sponged  out  with  iodin.  In 
a  few  weeks  the  patient  was  entirely  well. 
An  operation  which  has  been  done  in 
several  cases  for  the  closure  of  naso-oral 
fistula  may  be  described  as  follows :  As- 
suming that  the  labial  gingival  structures 
are  completely  destroyed  and  that  the 
lingual  periosteum  and  mucous  mem- 
brane extend  well  do^vn  to  the  normal 
line,  two  incisions  are  made  through 
the  latter  structure,  either  with  scissors 
or  knife,  back  up  to  the  orifice  of  the  fistula  and  far  enough 
back  on  the  two  sides  to  make  the  tongue  wide  enough  to 
cover  the  opening.  The  end  margin  of  the  flap  thus  made 
is  freshened  and  the  corners  made  round.  The  next  step 
is  to  freshen  the  orifice  of  the  fistula  for  a  distance  equal  to 
the  thickness  of  the  flap.  The  flap  is  now  turned  up  over 
the  orifice  of  the  fistula  and  sutured  there  with  chromicized 
catgut.  In  the  three  cases  in  which  the  operation  has  been 
performed  the  results  have  been  satisfactory  (Figs.  45, 
46,  47). 


Fig.  44. — Sequestrum 
Removed  from  the 
Maxilla.  Note  the 
opening  through  the 
process  from  the 
apex  of  the  tooth 
socket,  mdicating 
the  point  where  the 
original  alveolar  ab- 
scess which  was  the 
cause  of  the  trouble 
spontaneously 
opened  through  the 
bone,  and  by  bur- 
rowing under  the 
periosteum  de- 
stroj-ed  the  nutrition 
to  the  bone  in  every 
direction  until  three 
teeth  were  involved. 
This  typically  illus- 
trates what  occurs 
in  all  cases  of  failure 
to  promptly  incise 
alveolar  abscesses. 


ACUTE    SUPPURATIVE   DISEASES 


195 


Fig.  45. — Method  of  Closing  Naso-oral  Fistula,     a,  opening   into    nose- 
b  and  c,  incisions;  d,  flap  to  be  turned  upward  and  outward  over  a. 


Fig.  46. — Completed  Operation  for  Naso-oral  Fistula,     a,   fistula  with 
flap  over  it;  d,  flap  in  new  position;  e,  sutures. 


196 


DISEASES    OF    THE    MAXILLA 
TUBERCULOUS  DISEASES 


These  conditions,  per  se,  are  not  so  common  as  those 
associated  with  acute  infection  and  syphilis,  but  are  occa- 
sionally found  associated  with  lupus  and  secondary  to  a 
general  infection.     The  course  is  very  chronic  and  never 


Fig.  47.— Final  Result  of  Operation  Shown  in  figs.  45  and  46. 

becomes  active  unless  mixed  infection  occurs.    For  further 
consideration,  see  chapter  on  Tuberculosis. 


DISEASES    OF    THE    BONES    DUE    TO    LESIONS    IN  THE 
CENTRAL  NERVOUS  SYSTEM 

Tabetic  Disease  of  the  Maxillary  Bones 

In  tabes  dorsalis  (locomotor  ataxia)  any  bone  of  the 
body  may  become  inflamed  and  disintegrate.  In  cases  of 
obscure  inflammatory  changes  of  the  jaw  during  middle 


DISEASES   DUE   TO   NERVE   LESIONS  197 

life,  it  is  well  to  bear  in  mind  these  causes  and  consider 
other  tabetic  symptoms.  The  course  is  chronic.  The  teeth 
eventually  fall  out.  There  is  anesthesia  of  the  gums  and 
possibly  of  the  lips.  There  may  be  atrophy  or  suppuration 
with  sequestration. 

Local  treatment  consists  in  meeting  the  acute  demands. 
No  permanent  impression  can  be  made  short  of  constitu- 
tional treatment,  which  is  directed  to  the  sclerotic  changes 
in  the  spinal  cord.  Some  of  these  cases  are  specific  and  a 
Noguchi-Wassermann  test  should  be  made  and,  if  positive, 
salvarsan  treatment  should  be  given. 

Acromegaly 

Acromegaly  is  a  chronic  hypertrophy  of  the  bones  and 
other  parts  of  the  body,  and  is  of  a  nervous  origin.  It  is 
also  known  as  Marie's  malady,  because  a  French  physician 
of  that  name  furnished  the  first  accurate  description  of  a 
case  in  1888.  The  morbid  change  which  is  supposed  to  be 
the  cause  of  the  extraordinary  growth  is  possibly  located 
in  the  pituitary  body,  but  similar  changes  are  also  found 
in  the  thyroid  gland.  It  is  associated  with  impairment  of 
the  senses,  and  is  characterized  by  abnormal  growths  of  the 
skeleton,  especially  of  the  bones  of  the  face,  hands  and  feet. 
The  hypertrophy  extends  to  the  skin,  nails,  muscles,  glands 
and  other  soft  structures. 

So  uniform  and  symmetrical  is  the  growth  in  some  in- 
stances that  the  afflicted  pose  in  museums  as  giants.  Cor- 
nelius McGrath,  the  Irish  giant,  who  was  seven  feet  and  six 
inches  tall,  and  the  great  American  giant,  who  measured 
seven  feet,  eight  and  three-quarter  inches,  were  possibly 
both  acromegalics.  In  many  of  the  recent  cases  reported, 
the  tendency  has  been  to  hypertrophy  of  the  mandible. 

Leontiasis  Ossea 
Leontiasis  ossea  is  an  hypertrophy  of  the  bones  of  the 
face  and  skull.     The  affected  bones  appear  to  grow  uni- 


198 


DISEASES    OF    THE    MAXILLA 


formly  in  all  directions,  pressing  npon  vital  parts,  closing 
foramina  and  thus  destroying  tlie  nerves  and  blood  vessels 
wliicli  pass  through  them.  When  the  maxilla  or  frontal 
bones  are  involved,  the  eyeball  may  be  pushed  from  the 
orbit,  and  the  antral  or  nasal  cavities  may  be  entirely  ob- 
literated. 

The  growth  is  usually  bilateral.     Pain  is  a  prominent 
symptom.    Loss  of  function  with  great  deformity  follows. 


Fig.  48. — Acromegaly. 

The  course  is  very  slow,  requiring  years  before  marked  en- 
largement or  severe  pain  is  developed.  The  hypertrophy 
is  doubtless  of  central  origin,  since  both  sides  are  uniformly 
involved.  Treatment  with  the  hope  of  stopping  the  growth 
is  not  known.  When  nerves  are  pressing  upon  the  bone 
the  latter  may  be  chiseled  away  to  relieve  the  pressure. 

Under  the  title  of  "Diffuse  Hyperostosis  of  the  Upper 
Maxilla,"  L.  Poisson,  of  Nantes,  discusses  the  curious  and 
obscure  condition  known  more  familiarly  by  the  name  of 
leontiasis  ossea  (Virchow).  This  disease  is,  by  its  course, 
more  or  less  symmetrical  in  character,  and  is  distinguished 


REGENERATION   OF   BONE  199 

absolutely  from  the  exostomas  of  the  antrum,  which  involve 
the  surrounding  parts,  also  from  the  eburnated  exostoses 
of  the  face,  osteoperiostitis  (intra-  or  extra-alveolar),  and 
from  the  hypertrophic  variety  of  osteoperiostitis.  It  is 
equally  distinguished  from  sarcoma,  which  may,  however 
(in  two  cases,  at  least,  that  were  reported  by  Le  Dentu  and 
Pacquet),  graft  itself  upon  preexisting  hyperostosis.  The 
reported  cases,  if  we  accept  only  those  which  are  indisput- 
able, are  not  very  numerous,  numbering  about  ten  in  all. 
The  oldest  observation  is  Eibell's  (1823).  The  symptoms 
observed  are  uniform  enough  to  permit  of  a  general  de- 
scription and  even  to  allow  an  attempt  at  definition  of  this 
affection.  It  may  be  said  to  be  a  disease  characterized  by 
the  hyperostosis  that  is  most  often  bilateral  and  symmetri- 
cal; which  begins  ordinarily  by  attacking  the  upper  jaws, 
and  especially  their  antra  ;  which  causes  prominences  under 
the  skin  of  the  face  and  projections  into  the  nasal  passage ; 
which  tends  to  propagate  itself  into  the  bones  of  the  face 
and  cranium;  which  makes  its  debut  in  youth,  and  pro- 
gresses with  exceedingly  slow  steps  until  it  ends  in  death 
by  virtue  of  the  fatally  progressive  development. 

REGENERATION  OF  BONE 

Every  part  of  every  bone  is  develojDed  from  its  own 
center  of  ossification,  and  bone  growth  is  not  only  from  the 
periosteum,  but  from  the  endosteum,  which  receives  its 
blood  supply  from  the  arteries  which  enter  the  nutrient  for- 
amina and  pass  along  the  medullary  canals.  While  the 
periosteum  furnishes  the  material  for  the  circumferential 
growth  of  the  bone,  its  longitudinal  growth  is  j^rincipally 
from  the  diaphyseal  side  of  the  epiphyseal  cartilage,  which 
receives  its  blood  supply  from  the  central  canal  of  the  bone, 
and  not  from  the  periosteum. 

Death  of  bone  is  in  proportion  to  the  destruction  of 
nutrition.  In  osteomyelitis,  the  nutrient  vessels  in  the  cen- 
tral canal  are  destroyed  for  the  entire  length  of  the  shaft, 


200  DISEASES    OF    THE    MAXILLA 

and  the  bone  becomes  a  sequestrum  and  is  cast  off,  the  peri- 
osteum being  lifted  from  its  surface  as  the  infection  ex- 
tends to  this  part  of  the  bone.  The  new  bone,  known  as 
chloaca,  is  deposited  in  concentric  layers.  The  experiments 
of  Wieder  determined  that  when  the  sequestrum,  or  old 
bone,  was  removed,  the  periosteum  did  not  have  the  same 
power  of  regenerating  bone,  but  produced  cartilage  mainly. 
This,  however,  is  due  to  the  fact  that  when  the  entire  bone 
is  removed  early  the  periosteum  collapses  one  side  against 
the  other,  and  the  regenerated  bone  is  much  smaller  than 
if  it  were  formed  around  the  sequestrum. 

In  cases  where  a  less  extensive  area  has  been  deprived 
of  its  nutrition,  a  somewhat  different  course  of  reproduc- 
tion is  found.  In  periostitis  or  osteomyelitis,  where  a  small 
portion  of  bone  is  exposed  or  deprived  of  its  periosteum, 
the  sequestrum  which  is  cast  off  may  be  a  very  small  part 
of  the  entire  bone.  The  line  of  demarcation,  or  that  line 
between  the  dead  and  the  living  tissue,  is  well  established, 
and,  when  the  sequestrum  is  cast  off,  the  periosteum,  when 
it  is  permitted  to  do  so,  becomes  adherent  to  the  living  bone 
and  the  cavity  is  in  that  way  obliterated,  but  there  is  inter- 
posed between  the  old  bone  and  the  periosteum  a  consider- 
able amount  of  new  bone.  In  some  instances,  as  is  illus- 
trated in  the  chapter  on  diseases  of  the  mandible,  the 
bone  may  be  deprived  of  its  periosteum  on  account  of  an  in- 
flammation, yet,  when  the  inflammatory  serum  is  permitted 
to  escape  or  when  the  infected  area  is  treated  by  curette- 
ment  or  disinfection,  followed  by  a  complete  adjustment  of 
the  periosteum  to  the  bone  with  sutures,  exfoliation  does 
not  take  place. 

The  foregoing  general  comments  are  introduced  in  order 
that  the  regeneration  of  the  mandible  after  destruction  may 
be  better  understood.  The  histories  of  the  following  cases 
are  reported,  which  tjqpically  illustrate  the  method  of  re- 
generation of  this  bone  after  disease.  Early  operations 
may  be  performed  to  prevent  sequestration,  but  when  it  is 


REGENERATION  OF   BONE 


201 


decided  that  a  considerable  piece  of  the  entire  shaft  must 
be  cast  off,  operation  should  be  postponed  until  the  new 
bone  has  formed  around  the  sequestra,  as  the  following 
cases  fully  demonstrate.  The  time  required  for  the  repro- 
duction of  bone  is  several  weeks,  and  it  is  recommended 
that  too  much  time  be  allowed  rather  than  not  enough. 

A  boy,  aged  eight,  had  what  was  considered  ordinary 
toothache,  but  which  became  so  severe  that,  on  the  ninth  day 
after  the  onset,  he  was  taken  to  a  hospital  and  a  surgeon 
did  an  operation  for  abscess.  Two  months  later  a  second 
operation  was  performed,  at  which  time  the  face  was  ex- 


FiG.    49. — Sequestrum    Removed    in    Case    Described    in    Text.     Result 

Shown  in  Fig.  50. 

ceedingly  swollen  and  the  periosteum  was  gone  from  the 
bone,  and  a  piece  of  bone  was  removed.  Ten  months  later 
a  third  operation  was  performed,  and  the  sequestrum,  as 
shown  in  Fig.  49,  was  removed  through  the  mouth.  Fig.  50 
shows  the  perfect  articulation  between  the  teeth  as  evi- 
dence of  a  perfect  reproduction  of  the  left  half  of  the  man- 
dible from  the  sigmoid  notch  to  the  symphysis.  The  bone 
came  aw^ay  in  four  pieces,  but  represented  the  entire  half 
except  the  condyle.  Had  not  sufiflcient  time  elapsed  from 
the  onset  of  the  trouble  until  the  removal  of  the  bone  for 
the  regeneration  of  the  new  bone  around  the  sequestrum, 
great  deformity  would  have  resulted.  All  of  the  teeth  on 
the  left  side  had  been  extracted  at  the  time  of  the  two  pre- 
ceding operations. 


202  DISEASES    OF    THE    MAXILLA 

Fig.  51  is  introduced  to  show  a  typical  papilla,  indicat- 
ing that  there  is  denuded  bone,  with  usually  a  sequestrum 
back  of  it.  When  this  granuloma  is  found,  an  opening  is 
always  present  in  its  center  which  leads  into  the  necrotic 
area.  The  exuberant  granulations,  which  are  observed 
around  the  orifice  of  a  sinus,  represent  a  condition  com- 
monly known  as  "proud  flesh,"  a  growth  or  proliferation 
of  the  histological  elements  of  the  tissue  involved,  indicat- 


FiG.  50. — Perfect  Articulation  Following  Operation.     Described  in  Text. 

ing,  in  instances  where  it  is  around  a  sinus,  carious  bone, 
but  indicating  on  the  surface  of  the  body  exuberant  growth 
and  a  favorable  condition  rather  than  an  unfavorable.  If 
on  the  surface  of  the  body,  it  may  be  removed  by  the  use 
of  scissors  or  lunar  caustic,  or  will  disappear  under  pres- 
sure. When  around  a  sinus  leading  into  bone,  cauteriza- 
tion is  of  no  value  except  to  remove  the  granulation  tempo- 
rarily, for  so  long  as  the  bone  is  disintegrating  the  granu- 
lation tissue  will  be  re-formed  in  the  course  of  a  few 
weeks. 


REGENERATION   OF  BONE 


203 


A  young  woman,  aged  twenty,  was  having  the  left  first 
molar  and  the  second  bicuspid  prepared  for  filling.  The 
usual  treatment  was  being  carried  out  to  destroy  the  nerve 
preparatory  to  the  filling  of  the  root  canal.  Pain  and  swell- 
ing were  marked  symptoms.  Pain  began  on  the  left  side 
and  extended  around  to  the  right  along  the  body  of  the  man- 


FiG.  51. — Papilla  prom  Necrosis. 

dible.  Two  months  after  the  onset  of  the  trouble  an 
abscess  showed  itself  under  the  chin  and  was  incised.  A 
sinus  was  established  and  the  discharge  was  continuous  for 
another  month,  when  she  was  taken  to  the  hospital,  and, 
through  the  incision  shown  in  Fig.  52,  the  body  of  the  bone 
was  removed,  as  represented  in  Fig.  53.  After  the  opera- 
tion was  over,  complete  separation  of  the  bone  was  found 


204 


DISEASES    OF    THE    MAXILLA 


at  points  where  the  two  teeth  had  been  treated.  The  pa- 
tient described  it  by  saying  that  ''the  jaw  fell  to  one  side 
when  she  was  lying  down".  There  were  several  openings 
into  the  mouth  on  the  external  surface  of  the  mandible 
within  the  mouth,  as  well  as  a  large 
opening  through  the  skin  under  the 
chin.  Three  or  four  small  pieces  of 
bone  were  taken  out  of  the  mouth.  All 
active  symptoms  subsided  shortly 
after  the  operation  and  all  of  the 
sinuses  leading  into  the  mouth  closed 
and  the  patient  suffered  little  incon- 
venience after  that  time.  The  sinus 
continued  to  discharge  for  four 
months,  and  it  was  decided  that  suffi- 
cient time  had  elapsed  for  the  bone  to 
completely  repair  across  the  points  of 
fracture  and  that  whatever  was  causing  the  sinus  to  re- 
main open  should  be  removed.  The  wound  under  the  chin 
was  enlarged  and  the  root  of  the  bicuspid  on  the  right  side 


Fig 


52. — External  Ap- 
pearance. 


Fig.  53. — Area  Bone  Destroyed.  Diagrammatic  reproduction  of  bone  show- 
ing points  of  complete  destruction  of  bones  through  the  teeth  at  two  points 
and  a  central  point  communicating  with  the  left  central. 

was  found  extending  down  into  the  cavity.     After  its  re- 
moval the  sinus  closed.     It  was  found  that  the  bone  had 
completely  reproduced  itself  and  was  perfectly  firm. 
H.  H.,   aged  thirty,  presented  himself  with  a  mouth 


TECHNIQUE   OF   OPERATIONS 


205 


Fig.  54.— Teeth  To- 
gether. 


converted  into  a  pus  basin.  This  pu- 
trescent condition  had  existed  for  many 
months.  He  had  had  a  chancre  four 
years  before,  but  this  history  had  ap- 
parently been  overlooked,  for  specific 
medication  had  not  been  administered. 
An  examination  revealed  a  denuded  left 
mandible  from  symphysis  to  condyle. 
The  first  step  was  to  remove  the  entire 
right  body.  This  was  done  through  the 
mouth  with  a  pair  of  Cryer  universal 
upper  tooth  forceps;  the  ramus  was  re- 
moved with  great  difficulty,  the  bone 
coming  away  in  four  fragments.  The  ultimate  result  may 
be  seen  by  studying  Fig.  57.  Articulation  between  the  teeth 
in  the  remaining  half  of  the  mandible  and  those  in  the  cor- 
responding maxilla  is  as  nearly  perfect  as  possible.  The 
wound  itself  repaired  without  incident 
under  specific  medication.  This  case 
illustrates  that  many  extensive  in- 
cisions are  made  through  the  tissues 
of  the  face  for  operations  on  the  man- 
dible and  bones  of  the  face  that  could 
be  done  through  the  mouth.  Fig.  58 
shows  that  no  deformity  of  the  face 
is  present  either  from  unnecessary  in- 
cisions through  the  face  or  from  loss 
of  bone. 


Fig.  55. — Mouth  Open. 
Figures  54  and  55  show 
the  range  of  motion  of 
the  jaw  and  the  articu- 
lation of  the  teeth.  The 
arch  was ,  shortened 
slightly,  making  it  im- 
possible to  force  the 
incisors  far  enough  for- 
ward to  articulate  with 
the  upper  incisors. 


TECHNIQUE  OF  OPERATIONS  UPON 
THE  BONES  OF  THE  FACE 

The  technique  of  operations  upon 
the  alveolar  processes  and  the  contigu- 
ous structures  is  not  well  understood 
by    the    general    operating    surgeon. 


206  DISEASES   OF    THE    MAXILLA 

^1 


tfk^K 


--> 


^^l>c. 


Fig.  56. — Entire  Right  Half  of  Mandible  Removed  in  Four  Fragments. 


Fig.  57. — Result  After  Regeneration  of  Bone.     Teeth,  in  perfect  articula- 
tion on  left  side. 


TECHNIQUE    OF   OPERATIONS  207 

The  practicing  dentist  is  able  to  do  operations  upon  the 
mouth  and  the  teeth  that  would  be  considered  almost  im- 
practical and  impossible.  The  soft  tissues  extending  from 
the  oral  orifice  in  every  direction  to  the  point  of  attachment 
to  the  bones  of  the  face  are  very  yielding  and,  under  gentle 
or  continued  traction,  especially  during  profound  anes- 
thesia, every  part  of  the  mandible  can  be  reached  without 


Fig.  58. — Cosmetic  Result.    Bone  removed  tlirough  mouth.    Skin  incisiona 

not  necessary. 

incisions  through  the  skin.  So  also  may  the  maxilla  be 
reached,  up  to  the  infraorbital  foramen  through  the  mouth. 
General  practitioners  of  medicine  are  constantly  incis- 
ing through  the  skin  at  various  points  between  the  eye  and 
the  mouth  for  supra-alveolar  abscesses,  leaving  unsightly 
scars  and  in  no  way  establishing  proper  drainage.  So,  also, 
is  it  the  common  practice  to  incise  abscesses  of  the  man- 
dible along  the  external  surface  of  the  bone,  even  before 
an  effort  is  made  to  evacuate  pus  through  the  inferior  sul- 
cus of  the  mouth. 


208 


DISEASES   OF   THE   MAXILLA 


A  surgeon  was  recently  operating  in  a  hospital,  and, 
upon  inquiry,  it  was  learned  that  the  patient  had  necrosis 
of  the  mandible  in  the  region  of  the  molar  teeth.  As  a  great 
surprise,  it  was  observed  that  the  face  had  been  cut  from 
the  angle  of  the  mouth  to  near  the  angle  of  the  jaw,  for 


Fig.  59. — Mouth  Ketractor. 

the  purpose,  as  the  surgeon  said,  of  giving  him  more  room 
to  do  his  curettement.     Such  mistakes  are  too  frequent. 

By  referring  to  the  chapter  on  Ankylosis,  it  will  be 
learned  that  the  mandible  may  be  severed  at  any  point  half 
way  up  the  ramus  above  the  inferior  dental  canal  through- 
out its  entire  course.  The  only  incision  necessary  is  one 
not  longer  than  three-fourths  of  an  inch,  at  such  point  as 
to  permit  the  passage  of  the  Gigli  saw.  Indeed,  it  is  pos- 
sible to  remove  the  entire  mandible,  from  molar  to  molar, 
through  the  mouth  after  section  is  made  with  the  Gigli  saw, 
as  described. 


CHAPTER  XX 

TUBEKCULOSIS  OF  THE  FACE,  MOUTH  AND  JAW 

TUBERCULOSIS  OF  THE  FACE 

Tuberculosis  of  the  face,  as  classified  since  the  discovery 
of  Koch,  includes  many  affections  and  facial  blemishes  for- 
merly known  by  other  names.  Three  forms  will  be  de- 
scribed: (1)  Scrofuloderma;  (2)  Tuberculosis  cutis;  (3) 
Lupus  vulgaris. 

SCEOFULODEEMA 

Scrofuloderma  is  a  subcutaneous  or  glandular  form  of 
the  disease.  It  is  most  common  in  the  glands  of  the  neck, 
beginning  by  a  chronic  enlargement,  gradually  increasing 
in  size  and  becoming  softer  until  a  fluctuating  tumor  is  pres- 
ent. It  is  painless  and  doughy.  The  skin  becomes  bluish 
and  finally  opens  spontaneously,  discharging  a  serum.  Con- 
siderable skin  may  come  away,  leaving  a  ragged  ulcer  with 
undermined  edges.  The  course  is  chronic,  requiring  many 
months  to  repair,  if  left  untreated. 

TUBEECULOSIS  CuTIS 

Tuberculosis  cutis  develops  secondarily  to  tuberculosis 
of  the  internal  structures  or  organs.  It  is  most  frequently 
seen  at  the  muco-cutaneous  junctions,  such  as  the  mouth 
and  the  nose.  It  is  quite  rare.  The  ulcer  is  not  deep  and 
the  borders  are  irregular.  The  floor  is  filled  with  granu- 
lar tissue  from  which  is  excreted  a  sero-pus,  occasionally 
drying  into  crusts.  From  the  granular  floor  may  develop 
new  tubercular  nodules,  and  the  ulcer  increases  in  size  in 

209 


210  TUBERCULOSIS    OF    THE    FACE 

the  same  way.     There  is  little  tendency  to  heal.     Pain  is 
more  severe  than  in  other  tuberculous  troubles 

Lupus  Vulgaeis 

Lupus  vulgaris  first  shows  itself  as  several  brownish- 
red  spots,  usually  on  the  cheek  or  some  part  of  the  face  or 
hands.  The  spots  become  nodules  of  granular  tissue,  grad- 
ually increasing  in  number,  and  extending  in  every  direc- 
tion, until  eventually  several  may  coalesce,  constituting  one 
large  tubercle.     The  nodules  are  slightly  raised  above  the 


Fig.  60. — Tuberculosis  Cutis.     (Dr.  Geo.  C.  Johnston.) 

skin  for  a  time,  when  they  have  a  semi-transparent  ' '  apple- 
jelly-like"  appearance.  The  liquid  resulting  from  the  coal- 
escence may  be  absorbed,  and  the  center  collapse  and  cica- 
trize, leaving  a  pit  around  which  the  tuberculous  process 
extends  to  surrounding  structures.  Not  infrequently  the 
ulceration  extends  through  the  skin,  when  there  is  present 
the  usual  tuberculous  ulcer.  The  infection  extends  to  the 
deeper  structures,  even  to  the  muscles  and  periosteum,  and 
finally  to  the  bone,  when  left  untreated.  It  most  frequently 
attacks  the  exposed  parts  of  the  body,  such  as  the  face  and 
the  backs  of  the  hands. 

Etiology.— The  infection  of  the  skin,  mucous  membrane, 
or  glands,  enters  through  the  glandular  structure  by  in- 
oculation with  the  tubercle  bacillus.  It  is  most  common  in 
children,  and  is  not  hereditary  except  in  rare  instances. 


TUBERCTTLOSIS    OF    THE    FACE  211 

Pathology.— Lupus  of  the  skin  presents  the  following 
histological  elements :  (a)  Tubercle  bacillus ;  (b)  Granula- 
tion tissue  nodules;  (c)  Giant  cells. 

Diagnosis.— Lupus  vulgaris  must  be  differentiated  from 
simple  granular  affections,  as  acne,  epithelioma  and  syphi- 
lis. In  lupus  the  course  is  generally  markedly  chronic.  It 
usually  occurs  in  young  manhood,  and  nodules  are  gener- 


FiG.  61. — Lupus  Vulgaris  in  Early  Stage.     (Dr.   Geo.  C.  Johnston.) 

ally  found  about  the  margin  of  the  ulcer.  Epithelioma  or 
lupus  exedens  occurs  in  middle  or  advanced  age.  The  border 
is  smooth,  with  little,  if  any,  peripheral  involvement. 

Syphilitic  ulcer  of  the  face  runs  a  course  of  complete 
development  in  a  few  weeks,  while  lupus  requires  many 
years.  In  tertiary  syphilides  there  may  be  many  nodules 
rapidly  breaking  down  into  as  many  ulcers,  and  these  may 
rapidly  coalesce.  SjqDhilodermatic  ulcers  have  sharp-cut 
edges ;  in  lupus  the  skin  margin  drifts  off  into  the  depth  of 


212  .    TUBEECULOSIS    OF    THE    FACE 

the  granular  base,  and  may  be  quite  irregular  or  scalloped. 
The  .history  of  the  case  is  of  value  and  must  be  reckoned 
with.  Antisyphilitic  treatment  will  cut  short  the  progress 
in  the  one,  but  has  no  influence  on  the  other.  The  initial 
lesion  of  syphilis,  presenting  as  it  does  the  indurated  base, 
should  never  be  mistaken  for  lupus,  in  which  there  are  nod- 
ules instead  of  a  hard  ring  about  the  periphery. 

Prognosis.— The  j)rognosis  is  not  as  promising  as  might 
be  expected  since,  after  enucleation  of  the  ulcer,  the  infec- 
tion may  extend  to  other  jDarts.  This  is  especially  true  of 
skin  lupus,  which,  when  untreated,  extends,  and  repair  of 
the  ulceration  results  in  unsightly  cicatrices.  Under  early 
eradication  repair  takes  place  in  many  cases,  and  if  the 
general  condition  is  excellent,  there  is  no  great  probability 
of  its  return. 

Treatment.— Treatment  may  be  divided  into:  (a)  pre- 
ventive; (b)  general;  (c)  local. 

Preventive  Treatment.- — Since  tuberculosis  is  admitted 
to  be  inoculable,  gTeat  care  should  be  exercised  by  those 
who  have  to  do  with  tuberculous  cases  that  the  skin  of  the 
hands  is  constantly  disinfected,  especially  if  abrasions  exist. 
Those  who  are  members  of  tuberculous  families  should 
avoid  exposure.  Everything  about  should  be  repeatedly 
sterilized  and  made  antiseptic. 

General  Treatment. — This  includes  change  of  climate, 
the  internal  administration  of  tonics  and  a  nutritious  diet. 

Local  Treatment. — This  is  subdivided  into  medical  and 
operative.  Pure  tincture  of  iodin  is  to  be  preferred  for  the 
former,  since  it  does  not  sear  the  tissues,  is  more  iDenetrat- 
ing  and  more  readily  absorbed. 

Operative  treatment  consists  in  a  curettement  of  the 
floor  of  the  tuberculous  ulcer,  after  which  iodin  is  applied. 
If  the  exposed  surface  be  extensive,  it  may  be  closed  by 
Eiverdin's  method  of  skin  grafting,  practiced  from  time  to 
time  until  the  healing  occurs.  If  small  nodules  still  remain, 
or  develop  about  the  periphery,  they  should  be  promptly 


TUBERCULOSIS    OF    THE    MOUTH  213 

scooped  out.  Complete  enucleation  is  undoubtedly  the  ac- 
cepted method  of  treatment,  since,  if  thorough,  it  should 
completely  eradicate  the  disease.  Plastic  operations  should 
be  made  to  close  the  break,  if  skin  cannot  be  procured  from 
the  sides  to  reach  across.  The  cicatrix  left  after  healing  is 
white  and  irregular. 

Tuberculous  glands  should  be  enucleated,  and  if  this  is 
done  before  ulceration  occurs  return  is  not,  as  a  rule,  to  be 
expected.  Broken-down  glands  may  be  incised,  scooped  out 
with  a  spoon,  and  the  cavity  mopped  out  with  tincture  of 
iodin.  The  cavity  is  packed  with  iodoform  gauze  and  per- 
mitted to  granulate  from  the  bottom. 

TUBERCULOSIS  OF  THE  MOUTH 

The  protective  character  of  the  mucous  membrane  of 
the  mouth  and  the  digestive  action  of  the  saliva  greatly 
reduce  the  possibility  of  inoculation  of  this  membrane  by 
pathogenic  germs.  Earely  do  we  see  acute  infections  fol- 
lowing teeth  extractions.  It  is  quite  as  true  of  the  more 
subacute  and  chronic  forms  of  disease. 

Primary  tuberculosis  of  the  mucous  membrane  of  the 
oral  cavity  per  se  is  not  common.  It  is  usually  secondary 
to  lung  lesions.  Inoculations  have  occurred  from  cigars, 
pipes,  and  utensils,  and  from  kissing.  The  lesion  begins  as 
a  nodule,  followed  by  others  which  eventually  break  down 
into  an  ulcer.  They  are  usually  located  in  the  angle  of  the 
mouth  in  the  mucodermal  line,  or  on  the  tongue.  Secondary 
involvement  from  the  primary  oral  inoculation  is  not  un- 
common, the  metastatic  extension  being  along  the  lym- 
phatics. The  glands  of  the  neck  are  usually  enlarged.  In- 
fection of  glands  can  also  occur  through  open  root  canals  of 
decayed  teeth,  and  by  absorption  through  exposed  periden- 
tal membranes  where  recession  of  the  gums  has  occurred, 
as  in  pyorrhea. 

Secondary  lesions  of  the  mouth  may  develop  from  the 


214  TUBERCULOSIS    OF    THE    FACE 

face  through  the  month,  from  the  pharynx  along  the  fauces 
or  vehim,  or  the  sputum  from  the  lungs  may  inoculate  the 
mouth.  Regardless  of  the  method  of  inoculation,  the  course 
is  usually  the  same. 

The  primary  change  is  in  the  form  of  a  nodule  on  the 
tip  or  edge  of  the  tongue  or  on  the  oral  orifice.  There  may 
be  many  miliary  tubercles  that  become  vesicles,  eventually 
coalescing.  They  present  a  roughened  granular  appear- 
ance and  are  usually  elevated.  When  they  become  ulcera- 
tive, the  margin  is  defined  with  undermined  edges.  They 
also  develop  in  "rhagades",  or  simple  slits,  differing  from 
syphilitic  grooves,  which  are  branching  and  irregular.  The 
ulcers  of  the  miliary  form  are  small  and  have  a  yellowish 
base  with  a  surrounding  red  zone,  which  eventually  devel- 
ops other  miliary  nodules.  The  entire  base  is  infiltrated. 
The  lesions  are  sensitive.    General  health  declines  rapidly. 

Prognosis. — Prognosis  in  the  primary  form  is  favorable. 
When  secondary  to  other  tuberculous  lesions,  the  pri- 
mary condition  governs  the  outcome.  Treatment  in  the 
primary  form  is  local.  Curettement  of  the  miliary  lesions 
under  cocain  is  acceptable.  When  larger  ulcers  involve 
a  considerable  portion  of  the  tongue,  enucleation  should  be 
done.  Cocain  may  be  brushed  over  the  tongue  to  control 
pain  at  all  times.  The  general  health  must  be  improved. 
X-ray  treatment  of  all  tuberculous  lesions  of  the  face  or 
mouth  is  of  undoubted  value  and  should  be  used  as  soon  as 
a  diagnosis  has  been  made.  Many  cases  of  lupus  vulgaris 
and  tuberculous  ulcerations  melt  away  under  the  rays  prop- 
erly focused. 

Dr.  Richard  L.  Sutton  reports  a  very  interesting  case 
of  recurring  necrosis  of  the  gingival  mucosa,  and  draws 
the  following  conclusions : 

"Although  it  is  not  possible  to  generalize  from  the  data 
secured  in  a  single  case,  the  following  deductions  may  safely 
be  drawn; 

"Periadenitis  mucosa  necrotica  recurrens  is  a  chronic 


TUBERCULOSIS    OF    THE    MOUTH 


215 


recurring  necrotic  granulomatous  affection  of  the  lingual 
and  buccal  mucosa.  Pathologically,  the  disease  is  charac- 
terized by  an  intense  inflammatory  process  in  the  periglan- 
dular tissues,  with  ensuing  necrosis,  and  separation  of  the 
central  part  of  the  affected  area. 

"It  is  probable  that  the  disorder  is  tuberculous  in  ori- 
gin. The  course  of  the  disease  strongly  points  to  a  long- 
standing, general  intoxication,  which  periodically  gives  rise 


i 

E       '-^ 

i| 

^H^r^"^  IK 

AH 

] 

Fig.  62. — -Periadenitis  Mucosa  Ne- 
CROTiCA  Recurrens.  Mature  lesion 
on  tongue  (plug  was  thrown  off 
twelve  hours  later.)  (Sutton,  Jour- 
nal of  Cutaneous  Diseases.) 


Fig.  63. — -Periadenitis  Mucosa  Ne- 
CROTiCA  Recurrens.  Depression 
left  by  a  recently  detached  plug.  The 
condition  of  the  gums  also  is  shown. 
{Journal  of  Cutaneous  Diseases.) 


to   acute  local  manifestations,  intensely  inflammatory  in 
character." 

Illustrative  Case. — The  author  herewith  reports  another 
case  of  this  very  rare  ulceration.  A  man,  aged  thirty-one, 
has  a  family  history  which  is  good,  with  the  exception  of 
one  sister's  dying  with  tuberculosis.  The  patient  has  al- 
ways been  well,  although  his  appearance  is  not  robust.  He 
had  an  ulceration  of  the  posterior  sulcus  of  the  mouth  on 
the  left  side,  external  to  the  molars.  This  occurred  about 
eighteen  months  ago.  This  ulcer  was  oblong,  being  about 
half  an  inch  wide  and  an  inch  long.  The  only  assignable 
cause  for  it  was  the  irritation  of  a  bridge.  It  healed  after 
five  months,  leaving  a  distinct  scar.    Seven  months  ago  ul- 


216 


TUBERCULOSIS    OF    THE    FACE 


ceration  began  back  of  the  right  molar  on  the  palatal  side 
and  gradually  increased  until  it  involved  the  internal  pos- 
terior surface  of  the  last  molar  and  the  soft  tissues  over  it 
about  an  inch  and  a  half  long,  reaching  over  the  palate  half 
an  inch  from  the  internal  surface  of  the  molar.  The  su- 
perior apex  of  the  ulcer  stands  inward,  within  a  quarter  of 
an  inch  from  the  median  line.     The  soft  tissues  are  de- 


] 
1 

L 

^ 

*^    ■ 

k 

w 

CiSK 

':  w 

Fig.  64. — Tuberculosis  of  the  Mouth.  (Foote.) 

stroyed  back  of  the  tooth  for  a  considerable  distance,  so 
that  a  probe  can  be  passed  up  into  it  at  least  half  an  inch. 
The  surface  of  the  ulcer  is  very  granular,  the  granulations 
being  the  size  of  half  a  grain  of  wheat.  The  margin  is  dis- 
tinctly outlined  and  everted  slightly.  There  is  practically 
no  hemorrhage  from  the  surface  of  the  ulcer.  A  Noguchi- 
Wassermann  test  was  negative,  as  was  also  a  microscopic 
examination  of  the  granulations,  and  a  culture  of  the  bacte- 
rium from  the  surface  of  the  ulcer  showed  no  special  germs. 
Treatment. — Tincture  of  iodin  was  applied  at  the  first 


TUBERCULOSIS   OF   THE    FACIAL   BONES  217 

visit,  and  by  the  time  the  pathologist  was  ready  to  report 
the  ulcer  was  greatly  iniproved.  A  second  treatment  made 
further  rejoair,  and  it  had  reduced  about  half  its  original 
size.     The  case  is  still  under  treatment. 

TUBERCULOSIS  OF  THE  FACIAL  BONES 

While  not  common,  a  sufficient  number  of  cases  of  tuber- 
culosis of  the  facial  bones  occur  to  demand  special  mention. 
It  is  rare  per  se,  and  is  usually  secondary  to  other  foci. 

When  primary,  the  inoculation  occurs  after  an  injury  of 
the  gingival  tissues,  or  through  some  abrasion  caused  by 
calculi,  carious  teeth,  or  chronic  granulation  about  the 
teeth.  The  reduced  condition  of  the  system  from  typhoid, 
measles,  and  other  acute  diseases,  is  a  forerunner  of  tuber- 
culous diseases.  The  inoculation  is  followed  by  a  swelling 
and  infiltration  of  the  tissues.  The  bone,  in  the  course  of 
several  weeks,  melts  away  or  becomes  sequestered,  and  is 
cast  off,  if  not  removed  by  operation. 

The  primary  focus  may'  also  be  located,  either  in  the 
bone  or  periosteum,  anywhere  over  the  maxillary  bones. 
The  margin  of  the  orbit  or  the  malar  or  palatal  processes 
may  be  primarily  involved.  The  disease  gTadually  extends 
over  the  entire  bone,  unless  cut  short  by  early  incision, 
curettement,  and  disinfection. 

Mandibular  tuberculosis  runs  a  different  course  from 
tuberculosis  of  the  maxilla.  The  first  s}Tnptom  is  a  diffused 
thickness  of  the  tissues,  dense,  uniform,  and  not  very  pain- 
ful. Constitutional  symptoms  are  absent  or  very  mild.  As 
in  other  tuberculous  bone  disease,  the  muscles  are  in  s^Dasm 
and  their  trismus  especially  marked  when  the  insertion 
of  the  masseter  or  internal  pterygoid  is  involved.  The  teeth 
become  loose,  and,  when  not  extracted,  drop  out.  The  teeth 
are  too  frequently  considered  the  cause  and  extracted. 
The  disease  tends  to  extension  in  every  direction  and  the 
entire  mandible  to  the  articulation  with  the  temporal  is 


218  TUBERCULOSIS    OF    THE    FACE 

involved,  as  a  rule.  The  glands  of  the  neck  are  enlarged. 
It  requires  months  or  years  to  end  fatally.  Mixed  infec- 
tion with  suppuration  must  be  expected. 

When  the  bone  becomes  diseased,  secondary  to  a  pri- 
mary focus  in  the  lungs,  hips,  spine,  or  from  a  lupus,  the 
course  is  more  acute.  The  constitutional  symptoms  are 
more  marked  and  suppurative  periostitis  is  developed. 
Pain  is  more  marked,  and  the  stage  of  seciuestration  must 
be  expected  earlier  than  in  the  primary  variety. 

Diagnosis  must  be  made  from  syphilis,  actinomycosis, 
sarcoma,  and  periostitis  from  staphylococcus.  The  glandu- 
lar involvement  is  more  prominent  in  tuberculosis.  In  sar- 
coma this  is  absent,  late  in  actinomycosis,  and  not  so  marked 
in  syphilis. 

Treatment,  if  results  are  to  be  obtained,  must  be  radical 
at  all  stages.  Incision,  chiseling  back  to  healthy  bone,  re- 
moval of  all  diseased  soft  tissue,  and  disinfection  with  tinc- 
ture of  iodin,  form  the  most  acceptable  practice.  Forced 
feeding  and  open-air  life  are  just  as  important  as  they  are 
in  tuberculosis  of  the  lungs. 


CHAPTER    XXI 


SYPHILIS  OF  THE  MOUTH 


The  number  of  plivsicians  and  dentists  who  are  inocu- 
lated with  syphilis  during  the  administration  of  service  is 
quite  surprising.  A  leading  gynecologist,  whose  work  on  the 
subject  was  translated  into  five  languages,  contracted 
syphilis  from  a  patient  and  died  with  the  disease.  It  was 
the  author's  privilege  to  hear  the  address  of  the  president 
of  the  New  York  Academy  of  Medicine  about  twenty  years 
ago,  whose  voice  was  so  impaired  that  only  a  portion  of 
the  address  was  spoken  above  a  whisper,  due  to  the  contrac- 
tion of  the  disease  while  pursuing  his  duties  as  an  obstetri- 
cian. Five  dentists  have  presented  themselves  to  the  author 
with  chancres  on  their  fingers,  contracted  during  the  ex- 
traction of  teeth.  Many  physicians  and  surgeons  are  suf- 
fering with  this  disease,  in  the  majority  of  cases  contracted 
innocently. 

With  the  history  of  these  cases  before  us,  it  is  very 
proper  to  sound  a  note  of  warning  to  those  who  are  enter- 
ing into  the  practice  of  dentistry,  as  well  as  to  present  in 
the  most  realistic  form  possible  such  various  specific  lesions 
of  the  mouth  as  would  be  observed  in  patients  who  apply 
indiscriminately  for  treatment. 

Attention  is  called  to  the  classification  of  the  lesions  of 
syphilis  in  a  preceding  chapter  and  it  is  important  that  this 
classification  be  carefully  studied,  since  almost  every 
change  which  appears  on  the  skin  may  also  appear  on  the 
mucous  membrane  of  the  mouth.  It  must  not  be  thought 
that  the  disease  cannot  be  contracted  from  people  who  do 

219 


220  SYPHILIS    OF    THE    MOUTH 

not  have  mouth  lesions  or  other  lesions,  since  the  saliva, 
contaminated  with  secretions  from  mouth  lesions,  even 
microscopic  in  size,  is  most  virulently  inoculable  during  the 
entire  time  of  secondary  syphilis,  which  may  extend  over  a 
period  of  four  or  five  years.  During  this  time,  skin  and 
mucous  lesions  are  coming  and  going,  and  may  be  absent  at 
the  time  of  operation.  From  this  it  will  be  observed  that 
the  practice  of  prevention,  especially  during  the  extraction 
of  teeth,  would  be  the  proper  course,  and  this  is  best  accom- 
plished by  the  use  of  rubber  finger-stalls. 

Syphilitic  lesions  of  the  mouth  and  contiguous  tissues, 
which  are  of  importance  to  the  dentist,  may  be  presented 
as: 

1.  Initial  lesion. 

2.  Secondary  manifestations. 

a.  Erythema. 

b.  Mucous  patches. 

3.  Tertiary  lesions. 

a.  Gummata. 

1.  Tongue. 

2.  Cheek. 

3.  Tonsils. 

b.  Sclerosing  glossitis. 

c.  Ulcerative  gingivitis. 

d.  Bone  diseases. 

4.  Hereditary  lesions. 

a.  Teeth. 

b.  Soft  tissues. 

c.  Bones. 

THE  INITIAL  LESION 

The  initial  lesion,  already  described,  begins  as  an  ele- 
vated, hardened  papule,  the  margin  in  the  course  of  a  few 
days  increasing  in  height  above  the  skin,  producing  a  char- 


THE    INITIAL    LESION 


221 


acteristic  indurated  mass.  Location  of  cliancre  depends 
entirely  upon  the  point  of  inoculation,  usually  of  the  lips, 
or  it  may  be  of  the  tongue,  either  at  the  tip,  on  the  surface 
or  margin,  or  of  the  internal  surface  of  the  cheek,  and  even 
back  as  far  as  the  fauces.  There  may  also  be  present  ecthy- 
mic  papules  or  pustules,  or  erosions  resembling  the  condi- 
tion known  as  Vincent's  angina. 

The  surrounding  soft  tissue  is  usually  infiltrated,  and 
the  glands  of  the  neck  are  involved  quite  early.  The 
chancre  varies  in  size,  sometimes  growing  as  large  as  a 
nickel.  It  contains  well-defined  borders  and  is  bright  red, 
A\TLth  a  depression  in  the  center,  which  gives  it  the  appear- 
ance of  an  ulcer,  but  is  not  distinctly  one,  since  the  skin  is 
not  entirely  destroyed.  It  gives  off  a  serum  which  eventu- 
ally becomes  dry  and  forms  a  crust  over  the  entire  area  be- 
fore final  repair  occurs. 

The  initial  lesion  always  disappears  without  treatment 
in  the  course  of  several 
weeks.  The  secondary  mani- 
festations are  those  enu- 
merated in  Chapter  V,  un- 
der the  heads  of  ''Forms  of 
Syphilides,"  and  little  at- 
tention needs  to  be  paid 
them  here,  except  the  most 
common  forms. 

A  chancre  of  the  lip  is 
generally  on  the  vermilion 
border,  and  may  vary  in  size 
from  a  small  papule  to  a 
large  mass.  It  usually  be- 
gins as  a  small  oval  sore, 
with  a  raw,  flat,  shining  sur- 
face and  rounded  edges.  More  or  less  induration  devel- 
ops at  its  usual  time,  and  the  sub-maxillary  bubo  is  usually 
marked.    In   this   location  the   chancre   usually   occasions 


Fig.  65. — Chancre  op  Lip. 


222  SYPHILIS    OF    THE    MOUTH 

considerable  distress.  The  character  of  the  lesion  and 
the  appearance  at  stated  intervals  of  its  specific  features 
{induration  and  adenitis)  are  the  essentials  upon  ivhich  its 
nature  is  determined.  An  epithelioma  (cancer)  of  this  re- 
gion can  usually  be  differentiated  by  the  fact  that  it  is 
rarely  seen  in  persons  under  forty  years  of  age,  and  is  ex- 
tremely rare  in  women;  that  its  surface  is  irregular  with 


Fig.  66. — Chancre  of  Tongue.     (Dr.  Geo.  C.  Johnston.) 

everted  edges ;  that  it  develops  more  slowly ;  and  that  the 
involvement  of  the  anatomically  related  lymph  glands  ap- 
pears only  after  some  months  (usually  at  a  time  when  the 
chancre  would  have  healed  spontaneously). 

The  primary  lesion  may  appear  on  any  part  of  the 
tongue,  but  is  most  commonly  seen  on  the  dorsum  toward 
the  tip,  and  on  the  anterior  portion  of  the  border.  The 
lesion  is  likely  to  be  quite  large,  and  the  surrounding  tissues 
infiltrated  widely  by  the  lymphangitis.  The  induration  is 
of  cartilaginous  hardness,  and  subhyoid  adenitis  appears. 


SECONDARY   MANIFESTATIONS  223 

Chancre  of  the  gum  is  an  exceedingly  rare  lesion.  It 
appears  as  an  eroded  induration  surrounding  the  roots  of 
several  teeth. 

When  the  primary  lesion  develops  upon  the  tonsil,  it  is 
likely  to  be  mistaken  at  first  for  an  ordinary  sore  throat. 
There  are  the  general  and  local  symptoms  of  a  tonsilitis 
— fever  with  local  pain  on  deglutition  and  general  enlarge- 
ment of  the  tonsil.  When  due  to  syphilitic  infection,  the 
disease  is  unilateral.  The  chancre  may  appear  as  a  small 
eroded  papule,  but  more  commonly  the  tonsil  is  swollen  to 
double  or  triple  its  size,  and  covered  with  a  thick  adherent 
false  membrane,  under  which  the  surface  is  flat,  eroded,  or 
ulcerated.  The  surrounding  tissues  are  swollen.  Adenitis 
of  the  lateral  cervical  glands  develops.  All  of  the  glands 
of  this  region  may  be  enlarged,  but  the  largest  of  the  lym- 
phatics of  the  tongue  causes  a  visible  projection.  This 
largest  gland  is  difficult  to  palpate,  owing  to  its  situation 
under  the  middle  of  the  sterno-mastoid  muscle.  It  may  be 
on  or  at  the  angle  of  the  jaw.  Palpation  of  the  tonsil  with 
the  fingers  should  not  be  omitted,  as  it  reveals  a  marked 
induration — the  tonsil  is  firm  and  tense.  The  pain  on  deglu- 
tition is  severe.  The  tonsil  increases  rapidly  in  size.  It 
is  unusual  for  hemorrhage  to  occur,  as  is  common  in  malig- 
nant disease, 

SECONDARY  MANIFESTATIONS 

(a)  Erythematous  Syphilides.— Erythematous  syphi- 
lides,  sometimes  called  macular  or  roseola,  appear  in  bright 
red  blotches,  which  at  first  disappear  on  pressure,  but  later, 
when  pigmentation  develops,  leave  a  brownish  stain.  They 
are  located  on  the  fauces,  soft  palate,  and  sides  of  the 
tongue  and  cheek.  They  have  illy-defined  borders  and  are 
superficial. 

(b)  Mucous  Patches.— The  papular  varieties,  sometimes 
called  mucous  plaques  and  patches,  are  caused  by  cel- 
lular infiltration  of  the  mucous  membrane,  are  slightly  ele- 


224  SYPHILIS    OF    THE    MOUTH 

vated,  and  are  covered  with  a  grayisli-wliite  false  mem- 
brane, wliich,  when  it  exfoliates,  leaves  a  red  area  known  as 
papulo-erosive  plaque,  sensitive,  but  not  painful.  There  is 
no  induration,  as  found  in  a  chancre,  and  no  inflammatory 
zone.  The  patches  vary  in  size  from  one-eighth  to  one-half 
inch  in  diameter,  and  the  borders  are  irregular.  The  sur- 
face is  covered  with  hypertrophied  epithelium,  which  later 
becomes  macerated  and  takes  on  a  pale  gray  color,  and  is 
eventually  cast  otf,  leaving  a  superficial  ulcer,  which  may 
persist  for  several  weeks.  When  a  papule  is  found  in  the 
angle  of  the  mouth,  it  is  gray  on  the  mucous  membrane  and 
copper-colored  on  the  skin.  When  on  the  tongue,  it  is  dark 
in  color  and  has  a  mirror-like  smoothness,  called  by  Four- 
hier  ' 'plaque  lisse."  These  lesions  may  disappear  and  re- 
cur again  at  other  points,  or  they  may  persist  and  become 
papulo-hypertrophic. 

A  diffuse  symmetrical  erythema  of  the  fauces  may  pre- 
cede or  accompany  the  secondary  syphilides.  It  occasion- 
ally occurs  as  round  or  oval  areas  (macular).  This  diffuse 
redness  may  be  limited  by  a  sharply  defined  margin.  It 
persists  longer  than  an  ordinary  sore  throat.  It  is  almost 
always  present  when  the  first  mucous  patches  appear.  The 
mucous  patch  is  the  form  assumed  by  the  papular  syphilide 
when  occurring  on  the  mucous  membranes.  On  these  sur- 
faces it  is  not  markedly  elevated,  as  is  the  cutaneous  papule, 
and  its  surface  is  always  denuded.  It  occurs  as  an  erosion, 
a  circumscribed  diphtheroid  patch,  a  superficial  ulceration 
or  a  vegetating  papule. 

The  erosion  is  a  round  or  oval  infiltrated  area  but  little 
elevated  above  the  surrounding  surface,  flat  or  slightly 
convex,  and  denuded  of  its  epithelium,  showing  a  smooth  or 
slightly  roughened,  glistening,  moist  surface.  It  may  be  of 
raw-ham  color,  or  only  a  little  redder  than  the  surrounding 
mucosa.  It  varies  in  size  from  a  pin-head  to  a  split  pea  or 
larger.  It  appears  and  disappears  in  a  day  or  two,  or  may 
persist  several  days.    It  may  be  sensitive,  but  is  not  usually 


SECONDARY   MANIFESTATIONS  225 

so.  Its  site  of  election  is  the  dorsum  of  the  tongue.  When 
the  lesions  are  confluent,  the  outline  of  the  combined  lesion 
is  made  up  of  segments  of  circles. 

The  circumscribed  diphtheroid  patch  is  the  commonest 
form  of  the  mucous  papule.  It  occurs  on  the  tonsils,  uvula, 
free  border  of  the  soft  palate  and  its  pillars,  on  the  side  of 
the  tongue  and  on  its  under  surface,  on  the  inner  surface  of 
the  cheeks,  and  on  the  mucous  surface  of  the  lips.  It  elects 
particularly  the  pillars  of  the  fauces  and  the  tonsils.  It 
occurs  anywhere  in  the  mouth,  but  on  the  dorsum  of  the 
tongue  and  on  the  gums  less  frequently.  Commonly  lesions 
coexist  on  these  several  areas.  In  size  they  vary  from 
that  of  a  tack-head  to  a  finger-nail.  In  shape  they  are 
rounded  or  oval.  They  may  be  discreet  or  confluent  (then 
the  lesion  is  of  polycylic  outline).  As  occurring  in  the 
mouth,  the  diphtheroid  papule  is  usually  not  elevated,  but 
level  with  the  surrounding  surface  or  slightly  depressed  at 
the  center.  As  the  surface  of  the  papule  is  poorly  nour- 
ished, it  soon  becomes  macerated.  When  fresh,  it  is  of  a 
bright-red  or  raw-ham  appearance,  but  becomes  covered 
with  a  gray  or  grayish-yellow  pellicle  of  thickened  and  soft- 
ened epidermis,  giving  the  appearance  of  being  penciled 
with  the  nitrate  of  silver  stick.  This  pseudo-membrane  is 
usually  closely  adherent,  but  sometimes  can  be  separated 
and  leaves  a  bright-red  surface,  which  bleeds  easily.  This 
grayish  membrane  covering  particularly  the  central  portion 
after  a  time  sloughs  off,  leaving  an  abraded  lesion,  which 
may  become  more  deeply  invaded,  giving  a  shallow, 
well-defined  ulceration  with  a  mucoid  or  mucopurulent 
secretion.  There  is  no  induration  of  the  base.  The  sharp- 
cut,  well-defined  edge  is  surrounded  by  a  well-marked,  nar- 
row, hyperemic  areola,  and  beyond  this  there  is  often  a 
gray  ring  rendering  the  dimensions  of  the  lesion  larger. 
When  healing,  the  patch  loses  its  diphtheroid  covering,  pre- 
senting the  appearance  of  an  erosion,  and  ultimately  only 
a  pigmented  spot. 


226 


SYPHILIS    OF    THE    ^lOUTH 


A  patient  may  present  nnuierons  lesions  in  his  mouth, 
and  not  be  aware  of  their  existence,  as  they  may  cause  no 

pain  or  inconvenience.  The  mucous  patch  is  not,  as  a  rule, 
very  sensitive.  It  may,  however,  be  quite  sensitive,  particu- 
larly if  irritated  by  a  rough  tooth  and  inflamed  from  septic 
infection  (from  want  of  oral  hygiene),  and  hot  drinks  and 
^^^_  _^_^^^_  acid  foods  will  then  provoke  pain, 
^r^  ^i^^^H    ^^^  ^-^^  angle  of  the  mouth,  where 

I  ^itfPiPl^H    fissures  usually  develop,  it  is  quite 

W  ^^^^  ip3P" '^B  jtaiuful.  ()u  the  tonsil,  where  deep 
^  t  ?^|    ulceration  is  prone  to  occur,  it  may 

be  very  painful  and  interfere  with 
deglutition.  If,  during  its  course, 
from  irritation  or  sepsis,  the  jDatch 
becomes  distinctly  inflammatory, 
the  related  hmiph  glands  may 
swell  and  sometimes  suppurate. 
Local  irritation  acts  as  a  predis- 
FiG.  67.— Secondary  Le>iu.\    posiug  cause,  and  tobacco   (smok- 

WITH    SaLIVATIOX.  '  •  1  •  \  ••        •  i-l„ 

mg  or  chewing)  preeminently  so. 
The  mucous  jDatch  is  less  frequently  seen  in  women,  who 
do  not  smoke.  A  decayed  or  broken  tooth  may  determine 
the  site.  When  occurring  on  the  edge  of  the  tongue  it 
is  prone  to  ulcerate  on  account  of  contact  with  the  teeth. 
Mucous  patches  persist  as  a  manifestation  of  syphilis,  not 
through  persistence  of  the  individual  lesion,  but  by  the 
constant  development  of  new  ones.  AThen  they  appear 
as  late  lesions — that  is,  several  years  after  the  chancre 
— they  may  be  exceedingly  resistant  to  treatment.  "When 
the  patches  have  recurred  persistently,  and  ulceration  has 
been  deep,  the  mucous  membrane  of  the  tongue  and  buccal 
walls  may  be  glazed,  cracked  and  fissured.  There  is  no  ele- 
vation of  temperature  or  other  systemic  disturbance  ac- 
companying the  eruption  of  mucous  patches,  and  the  course 
of  each  lesion  is  slow  and  indolent.  They  must  be  differen- 
tiated from  Vincent's  angina  and  diphtheria. 


TERTIARY   LESIONS 
TERTIARY  LESIONS 


227 


(a) Syphilitic  Gummata.— Syphilitic  gummata  of  the 
tongue  and  mneons  meml)rane  of  the  month  are  manifest  in 
three  forms :  1.  Superficial  circumscribed  giimma  (tongue)  ; 


Fig.  68.— Gumma  of  Tongue.  (Palisade  Mig.  Co.) 

2.  Gummatous   infiltrations    (cheek) ;    3.    Gummata  of  the 
tonsil. 

1.  The  superficial  gumma  forms  a  distinct  protuber- 
ance, usually  in  the  anterior  third  of  the  tongue.  It  may 
be  in  the  mucous,  submucous  or  muscular  tissue.  It  varies 
in  size  from  a  bean  to  a  walnut.  There  may  be  several. 
The  surface  is  first  covered  with  smooth  mucosa,  but  breaks 
down  in  the  center  and  emits  a  dirty  yellow  mucilaginous 
discharge,  containing  lumps.    The  center  covering  breaks 


228  SYPHILIS    OF    THE    MOUTH 

away,  leaving  a  granular  nicer.  The  gummata  are  usnally 
in  the  horizontal  plane  and  involve  one  side.  When  multi- 
ple, they  may  develop  on  both  sides  simultaneously  and 
the  tongue  may  part  in  the  median  line,  leaving  a  bifid  con- 
dition, or  the  double  tongue  of  syphilis.  Destruction  con- 
tinues unless  arrested  by  treatment. 

2.  Gummatous  infiltration  more  frequently  involves  the 
cheek,  beginning  at  the  angle  of  the  mouth  and  extending 
backward,  resulting  in  the  characteristic  serpigenous  ulcer, 
and  eventually  perforating  the  cheek.  Other  parts  of  the 
body  are  usually  involved  at  the  same  time,  such  as  the 
bones  and  the  viscera.  The  soft  and  hard  palates  are  fre- 
quently the  seats  of  gummatous  infiltration.  Destructive 
lesions  usually  appear  first  in  the  nasal  cavity  or  pharynx, 
the  ulceration  extending  to  and  destroying  the  palate,  as 
the  two  reported  cases  demonstrate. 

A  differential  diagnosis  must  be  made  from  the  initial 
lesion  where  it  is  single  and  without  other  symptoms  and 
lesions ;  from  leucoplakia,  which  is  local  and  more  diffused 
and  not  nodular;  from  actinomycosis,  which  is  rare  and 
without  a  syphilitic  history,  and  in  which  the  lesion  is  more 
irregular  and  nodular;  from  tuberculosis,  which  is  most 
frequent  upon  the  tip  of  the  tongue,  beginning  on  the  sur- 
face as  a  small  tubercle,  eventually  becoming  ulcerative. 
The  borders  are  irregular  and  not  elevated. 

3.  Gummata  of  the  tonsil  and  soft  palate  are  commonly 
diagnosed  after  ulceration  has  occurred.  The  tonsil  is 
swollen  and  hard.  There  is  little  pain,  but  usually  some  in- 
terference with  hearing.  The  lymphatic  glands  behind  the 
angle  of  the  jaw  (contrary  to  the  general  rule)  are  usually 
inflamed  and  sensitive  from  mixed  infection.  A  gummatous 
infiltration  producing  redness,  tumefaction,  and  relative  im- 
mobility, may  develop  in  the  soft  palate,  causing  scarcely 
any  pain,  to  which  the  patient  may  pay  little  attention  until 
necrosis  sets  in  and  causes  ulceration,  perforation  or  de- 
struction.  Similar  processes  cause  perforation  of  the  hard 


TERTIARY   LESIONS 


229 


palate  and  commimication  between  the  nasal  and  oral  cavi- 
ties. Such  more  commonly  commence  in  the  nasal  struc- 
tures. Everyone  is  familiar  with  the  ultimate  contrac- 
tions, adhesions  and  deformities  resulting  in  these  cases. 

(b)    Sclerosing  Glossitis.— Sclerous  glossitis  is  a  char- 
acteristic lesion  of  syphilis.    No  other  condition  simulates 


Fig.  69. — Sclerosing  Glossitis  of  Syphilis. 

it.  The  tongue  is  increased  in  size  and  lobulated — deformed 
by  irregular  swellings  and  separated  by  deep  furrows.  The 
lobules  are  of  cartilaginous  density.  The  tongue  is  insensi- 
tive, clumsy  and  stitf.  The  swellings  are  caused  by  gum- 
matous infiltration  of  its  substance,  but  there  is  no  tendency 
to  softening  and  ulceration — the  masses  retain  their  hard- 
ness.   The  whole  tongue  may  be  affected,  or  there  may  be 


230  SYPHILIS    OF    THE    :\IOrTH 

only  a  few  infiltrated  areas.  Secondary  fissures  and  ex- 
coriations which  are  quite  sensitive  may  develop.  Ulti- 
mately gradual  and  progressive  contraction  of  the  gumma- 
tous deposit  leaves  the  tongue  smaller  than  normal. 

(c)  Ulcerating  Gingivitis.— Gingi\i-tis,  or  the  so-called 
pyorrhea  alveolaris.  which  has  received  so  much  attention 
from  dentists  during  the  past  few  years,  is  in  many  in- 
stances foimd  in  patients  who  have  had  syiDhilis,  either 
hereditary  or  acquired,  and,  indeed,  it  is  quite  difficult  to 
differentiate  between  these  conditions  without  a  Noguchi- 
TTassermann  reaction  and  without  medication  with  iodid  of 
potash.  TMien  of  a  syphilitic  nature,  the  ulcerations  disap- 
pear under  ''606"  and  iodid  of  potash  very  promptly,  but 
the  other  varieties  may  persist  for  many  years.  The 
following  case  is  reported  as  typically  illustrative  of  these 
conditions : 

A  woman,  aged  thirty,  had  been  treated  by  a  dentist 
for  a  few  weeks  for  trouljle  wliieli  began  as  an  ulceration 
about  the  molar  teeth,  during  Avhich  time  a  tooth  had  been 
extracted.  The  ulceration  continued  around  both  the  buc- 
cal septal  and  lingual  margins  of  the  gums  as  far  forward 
as  the  lateral,  and  the  ordinary  treatment  failed  to  check 
its  advance.  After  the  examination  it  was  observed  that 
some  of  the  process  was  denuded  of  periosteum  and  re- 
quired curettement.  For  confirmation  the  patient  was 
placed  upon  potassium  iodid  for  a  few  weeks  before  an  op- 
eration was  to  be  resorted  to.  About  this  time  an  ulcerative 
process  began  around  the  upper  teeth  on  the  same  side, 
and  it  was  decided  to  have  an  operation.  After  curetting, 
it  was  learned  that  the  family  physician  had  not  carried 
out  the  increasing  doses  of  saturated  solution  of  potassium 
iodid,  but  had  given  the  same  dose  three  times  a  day.  The 
patient  failed  to  improve,  however,  after-  the  operation,  and 
an  eminent  specialist  examined  the  case  and  confirmed  the 
diagnosis  of  specific  disease.  She  was  now  j)laced  upon  in- 
creasing doses  of  potassium  iodid,  until  she  was  taking  150 


TEETIARY   LESIONS  231 

grains  every  twenty-four  hours.  Within  a  few  weeks  the 
ulcerations  had  entirely  healed,  the  bone  had  covered  with 
reparative  material,  and  she  was  well.  The  patient  be- 
longed to  the  middle  class,  refined  and  intelligent,  and  no 
intimation  was  made  to  her  as  to  the  real  cause  of  the  trou- 
ble. The  diagnosis  was  unquestioned,  however,  as  nothing 
checked  the  advance  of  the  ulceration  but  specific  treatment. 

(d)  Syphilitic  Diseases  of  the  Facial  Bones.— These 
may  be  classed  as:  (1)  Acquired  syphilitic  bone  disease. 
(2)  Hereditary  syphilitic  bone  disease,  which  is  taken  up 
under  Hereditary  Lesions. 

Syphilitic  destruction  of  bones  of  the  face  runs  a 
chronic  course  and  is  rarely  confounded  with  the  acute 
varieties  of  necrosis.  It  is  only  possible,  how^ever,  to  dif- 
ferentiate these  destructions  from  periostitis  and  osteo- 
myelitis during  the  stage  of  sequestration  by  taking  into 
account  the  history  of  the  disease  and  the  general  history 
of  the  patient.  The  patient  who  has  had  a  chancre  will 
generally  withhold  the  fact,  and  many  will  positively  deny 
such  a  history  when  questioned  directly. 

Symptoms  of  the  most  importance  are  gradual  develop- 
ment without  acute  pain,  as  a  rule,  but  an  ache  during  the 
night.  Swelling  is  gradual.  Thickening  of  the  soft  tissues 
is  marked.  When  the  wound  becomes  suppurative,  show- 
ing mixed  infection,  the  development  is  more  rapid,  and 
pain  and  septic  symptoms  more  exaggerated. 

Diagnosis  must  be  made  from  other  destructive  diseases, 
such  as  periostitis  and  osteomyelitis,  from  streptococcic, 
staphylococcic,  tuberculous  and  chemical  etiology.  Here 
the  history  of  the  disease  is  valuable.  The  gradual  onset 
and  the  night  pain,  with  moderate  swelling,  are  most  prom- 
inent diagnostic  points. 

Treatment  is  constitutional.  In  no  case  should  the  knife 
be  used  except  to  remove  sequestra  or  to  liberate  an  active 
mixed  suppuration.  In  both  acquired  and  congenital  dis- 
eases, iodid  of  potash  in  some  form  is  as  near  a  specific 


232 


SYPHILIS    OF    THE    MOUTH 


as  any  medicine  known.  The  saturated  solution  of  the  crys- 
tals is  doubtless  the  best  form.  In  a  solution  of  one  ounce 
of  the  crystals  to  an  ounce  of  distilled  water,  a  drop  repre- 
sents a  grain  of  the  drug.  An  adult  should  begin  on  five 
drops  three  times  a  day,  after  meals,  in  milk  or  water.  In- 
crease one  drop  every  day  up  to  tolerance.  When  increased 
in  this  way  100  grains  have  been  given  at  a  dose  without 
injurious  effect.     Syphilitics  have  a  tolerance  for  iodids. 


Fig. 70.— Acquired  Cleft  Palate  from  Syphilis. 

PeojDle  who  have  not  had  the  disease  cannot  take  such  large 
doses.  lodid  of  potash  is  a  gastric  irritant  unless  given 
with  liquid  after  meals. 

Illustrative  Cases.— ¥{..  M.,  aged  twenty-nine  years,  had 
a  chancre  eight  years  ago,  with  usual  history  and  no  ter- 
tiary symptoms  until  two  years  ago,  when  he  had  begin- 
ning destructive  disease  of  the  nasal  bones  and  roof  of  the 
mouth.  In  spite  of  what  it  was  reasonable  to  suppose  was 
good  treatment,  the  destruction  continued  and  would,  no 
doubt,  have  destroyed  the  entire  maxilla.  lodid  of  potash 
was  pushed  to  sixty  grains  three  times  daily.  The  destruc- 
tion ceased,  and  repair  on  the  ulcerative  surfaces  was  com- 


TERTIARY   LESIONS 


233 


plete  in  one  year.  The  case  presented  a  most  extensive  de- 
struction. The  bones  in  the  roof  of  tlie  nasal  cavity  were 
so  destroyed  as  to  freely  expose  the  base  of  the  skull.  The 
ethmoid  cells  were  destroyed  well  up  to  the  cribriform 
plate.  At  no  time,  however,  were  there  any  cerebral  symp- 
toms. A  vulcanite  pros- 
thetic appliance  attached 
to  a  set  of  teeth  enabled 
the  patient  to  talk  well. 
An  aluminum  bridge  for 
the  nose  was  introduced 
through  the  under  surface 
of  the  lip  after  dissecting 
loose  the  mucous  membrane 
from  about  the  bony  nares.      ^^^-  71.-Sequesthum.     (G.  w.) 

This  resulted  in  producing  a  very  satisfactory  nose. 

G.  W.,  aged  forty,  gave  a  history  of  chancre  eight  years 
before  the  beginning  of  the  present  trouble.  Examination 
revealed  extensive  denuded  bone  in  the  central  part  of  the 

roof  of  the  mouth.  Under 
a  general  anesthetic  the  se- 
questrum, which  is  shown 
in  figure  71,  was  removed, 
as  well  as  the  floor  of  the 
nasal  cavities,  the  right  an- 
tral and  the  left  nasal  proc- 
esses of  the  maxillary  bone. 
This  represented  practi- 
cally the  entire  roof  of  the 
mouth.  Figure  72  shows 
the  condition  of  the  mouth 
after  the  operation.  Medication  was  continued  for  a  year. 
Packing  was  used  to  fill  the  immense  cavity  that  was  left 
after  the  removal  of  the  bone,  and  eventually  a  prosthetic 
appliance  was  made.  Incidentally  it  might  be  stated  that 
the  family  of  this  man  did  not  discover  that  he  had  any 


Fig.  72. — ^Appearance  of  Mouth. 


234  SYPHILIS    OF    THE    MOUTH 

difficulty,  so  perfect  was  liis  articulation  during  the  time 
he  used  the  packing,  as  well  as  the  denture. 

HEREDITARY    LESIONS 

That  heredity  plays  a  most  important  part  in  the 
production  of  bone  disease  of  the  faces  of  children  there 
can  be  no  doubt.  Indeed,  the  great  majority  of  cases  under 
twenty  years  of  age  have  a  syphilitic  ancestry. 

Surgeons  who  see  many  cases  of  bone  disease  of  young 
people  learn  to  recognize  this  factor  as  a  cause  of  hip,  knee, 
spinal  and  other  bone-  and  joint-destruction,  and  accord- 
ingly place  these  i3atients  on  constitutional  treatment  from 
the  beginning. 

(a)  Teeth.— Defects  in  the  size  of  the  teeth  are  charac- 
teristic of  hereditary  syi^hilis,  but  do  not  necessarily  imply 
its  i^resence.  The  Hutchinson's  teeth  (the  two  up^jer  cen- 
tral incisors  of  the  permanent  dentition),  with  concave, 
crescent-shaped  borders  directed  toward  the  median  line, 
have  until  recently  been  generally  accepted  as  definite  evi- 
dence, but  so  many  innocent  cases  are  met  with  in  dentistry 
as  to  invalidate  this  condition  as  a  symptom. 

An  acute  gummatous  infiltration  may  destroy  a  portion 
of  the  alveolar  border  of  the  inferior  maxilla.  It  begins 
as  a  swelling  around  the  root  of  one  or  more  teeth,  the  teeth 
become  loose,  and  in  a  few  days  or  weeks  a  portion  of  the 
alveolar  process  is  shed  and  the  teeth  come  out.  At  times 
the  process  may  be  checked  with  the  loss  of  little  or  no 
bone. 

(b)  Soft  Tissues.— By  referring  to  Chapter  Yl,  figure 
6,  a  case  of  multiple  gummata  of  hereditary  origin  will  be 
seen.  In  such  cases,  the  soft  tissues  are  probably  involved, 
and  occasionally  the  tissues  of  the  oral  cavity  are  attacked, 
but  not  so  frequently  as  some  other  parts  of  the  body.  The 
gummatous  infiltration  begins  as  a  granuloma  about  the 
teeth  or  of  the  tongue  and,  in  a  very  short  time,  extends  to 


HEREDITARY   LESIONS 


235 


the  deeiDer  structures,  involving  the  bone.     The  course  is 
practically  the  same  as  that  of  an  acquired  gTimma. 

(c)    Bones.— Bone  lesions  in  hereditary  cases,  as  a  rule, 
follow  upon  the  gummatous  stage,  and  the  destruction  is  in 


Fig.  73. — Hereditary  Necrosis.     Sequestrum  including  floor  of  the  antrum. 

proportion  to  the  extent  of  the  original  infiltrate.  Cases 
such  as  the  one  shown  in  figure  73  appear  to  be  self -limited, 
or  are  limited  by  constitutional  treatment.  But  such  cases 
as  that  shown  in  figure  6  have  several  gummatous  de- 
posits, as  will  be  observed  by  studying  the  history.  Treat- 
ment in  this  case  cut  short  further  formation  of  gurmnata, 


236 


SYPHILIS    OF    THE    MOUTH 


and  the  jDatient  recovered  without  return  of  the  symptoms 
after  several  years. 

Illustrative  Cases. — Girl,  aged  about  eleven,  shown  in 
figure  73,  with  a  history  of  hereditary  syphilis,  had  some 
form  of  operation  in  England  three  or  four  years  previous. 
As  may  be  observed  in  the  picture,  the  bone  was  denuded 
of  its  periosteum  throughout  the  entire  internal  and  ex- 
ternal surface  on  the  right  side  of  the  mouth.  Under  an 
anesthetic,  the  soft  tissues  were  retracted  up  to  the  antral 


Fig.  74. — Cleft  Palate  from  Hereditary  Syphilis. 

floor  and  to  the  nasal  cavity  and  were  removed.  This 
included  all  of  the  alveolar  process  up  to  these  cavities  and 
up  to  the  pterygoid  process.  The  sequestrum  removed  is 
also  shovTL  in  the  figure.  The  antral  and  nasal  floors  may 
be  observed.  It  will  also  be  noticed  that  a  molar  was  en- 
capsulated. Xeither  the  antral  nor  the  nasal  cavity  was 
entered.  Repair  followed  promptly,  but  the  patient  was 
placed  upon  constitutional  treatment  for  several  months. 
Another  girl,  aged  six  years,  had  diffused  syphilitic 
periostitis  of  the  tibia,  which  required  the  removal  of  a  se- 
questrum, after  which  recovery  followed  the  usual  treat- 
ment.    This  patient  returned  in  several  years  with  com- 


HEREDITARY   LESIONS  237 

plete  destruction  of  tlie  nasal  bones,  the  nasal  process  of 
the  maxilla,  the  nasal  septum  and  the  floor  of  both  nasal 
cavities.  The  hard  and  soft  palate  were  also  destroyed,  as 
well  as  the  faucial  walls.  The  destruction  was  extending 
in  every  direction.  Constitutional  treatment  stopped  the 
progress,  and,  barring  the  deformity  of  the  nose  and  ab- 
sence of  the  roof  of  the  mouth,  the  patient  enjoyed  good 
health.  A  return  may  be  expected  in  such  cases  unless  the 
iodids  are  continued  for  a  year  or  two,  and  the  patient  kept 
under  observation  for  several  years. 


CHAPTER  XXII 

TUMOKS   IN    GENERAL 

A  tumor  or  neoplasm  is  a  new  formation  or  localized 
swelling  composed  of  cells  which  more  or  less  conform  to 
the  tissue  in  which  the  tumor  is  developed,  and  having  no 
physiological  function.  Tumors  are  to  be  distinguished 
from  inflammatory  enlargements  associated  with  acute 
infections,  from  infiltrations,  and  from  hypertrophies. 

The  etiology  of  tumors  is  not  well  understood,  several 
theories  being  advanced.  Heredity  appears  to  play  some 
part  as  an  underlying  factor  in  the  growth  of  tumors,  since 
persons  who  have  had  parents  with  malignancy  have  a 
blood  or  cell  condition  favorable  to  the  growth  of  tumors 
of  a  similar  nature.  Statistics  show  that  about  twenty-five 
per  cent,  of  malignant  tumors  are  found  in  persons  whose 
ancestors  have  had  the  same  disease. 

Injuries  and  irritations  no  doubt  play  an  important  part 
as  the  cause  of  tumors,  as  seen  in  epithelioma  of  the  lip  from 
pipe  smoking,  and  carcinoma  of  the  breast  from  injuries. 

Infection  has  been  considered  by  some  authorities  as  a 
cause,  in  that,  in  certain  respects,  some  tumors  resemble 
infectious  processes  in  their  effect  upon  the  general  health 
and  their  tendency  to  metastasis. 

Other  investigators  have  determined  that  no  ordinary 
bacteria  play  any  causative  part.  The  possibility  of  ultra- 
microscopic  organisms  has  been  considered.  Secondary 
and  accidental  invasions  of  bacteria  into  tumors  may  occur 
and  lead  to  confusion. 

The  transplantation  of  tumors  from  one  part  to  another 
does  not  differ  from  ordinary  metastasis.  It,  however, 
proves  only  the  proliferative  tendency  of  the  cells  of  the 
growth,  and  not  the  infectious  origin. 

238 


CLASSIFICATION  OF   TUMORS 


239 


A  further  illustration  of  the  metastasis  of  tumors  is 
shown  in  a  case  where  a  thigh  was  amputated  for  sarcoma 
.  of  the  knee.  The  wound  healed  very  promptly,  and  the  pa- 
tient went  home  in  three  weeks.  In  three  months,  however, 
she  developed  sarcoma  of  the  lung,  which  destroyed  her  life 
very  rapidly.  The  cause,  or,  rather,  the  route  traversed 
by  the  cells  from  the  knee,  evidently  entered  the  system 
through  the  veins  before  the  amputation,  going  through 
the  venous  circulation  and  the  heart,  and  being  deposited 
in  the  lung  at  a  point  where  it  would  reach  the  first  capil- 
lary circulation. 

Classification.— Tumors  are  classified  both  from  a  histo- 
logical and  from  a  clinical  standpoint.  In  histological  classi- 
fication the  tumor  gets  its  name  from  the  embryonic  tissue 
from  which  it  grows,  or  from  the  character  of  the  tumor 
itself. 

Histologically,  tumors  may  be  classified  as  follows : 


Connective  Tissue  Group 


Odontoma  (tooth). 
Sarcoma  (fleshy). 
Osteoma  (bone). 
Fibroma  (fibrous). 
Lipoma  (fatty). 
Glioma  (nerve-like). 
Myxoma  (mucus-like). 
Encondroma  (cartilaginous) 

Carcinoma  (crab-like). 
Cystomo  (sac). 
Adenoma  (glands). 
Terotoma  (dermoid). 
Endothelioma  (serous). 

'Myoma  (muscle). 
Neuroma  (nerve). 

of  Tissue I  Angioma  (blood  vessels). 

[LymiDhangioma  (lymphatics). 


Epithelial  Group. 


Group  of  Higher  Order 


240  TUMOES   IN   GENERAL 

Clinical  classification  is  into  malignant  and  benign. 
Every  variety  in  the  above  table  is  benign,  except  two,  viz., 
sarcoma  and  carcinoma. 

1.  Benign  tumors  are  those  which  do  not  apparently 
affect  the  health.  They  are  dangerous  by  reason  of  their 
pressure  on  vital  parts  due  to  the  enormous  size  to  which 
they  may  grow. 

2.  Malignant  tumors  are  those  which  shorten  life.  A 
malignant  tumor  infiltrates  the  surrounding  tissue.  It 
tends  to  recur  after  removal.  It  spreads  to  distant  organs 
by  the  blood  vessels  and  lymphatics  (metastasis)  or  is 
transplanted  from  one  part  of  the  body  to  another.  A  spe- 
cific poison  is  formed  by  the  tumor  cell,  which  disturbs  the 
health  from  the  first,  and  the  patient  shows  a  peculiar  sallow 
complexion  known  as  a  cachexia. 

White  classifies  tumors  into  three  divisions:  (1)  Or- 
gan tumors,  (2)  tissue  tumors,  (3)  cell  tumors.  The  first 
and  second  classes  are  benign,  and  the  third  malignant. 

Fibroma.— Fibroma  is  a  benign  connective  tissue  neo- 
plasm, which  develops  from  any  of  the  different  fibrous 
tissues,  and  has  the  characteristics  of  the  tissue  from  which 
it  originates.  It  is  usually  dense,  but  sometimes  has  some 
elasticity,  due  to  the  presence  of  serum  within  the  meshes 
formed  by  the  loose  and  wavy  arrangement  of  the  slender 
fibrous  tissue.  Fibroma  usually  develops  in  the  skin,  in  the 
form  of  keloid  and  moluscum  fibrosum,  from  the  gums  (as 
fibrous  epulis),  from  nerve  sheaths,  the  uterus,  ovaries,  and 
intestines.  Keloid  is  a  pinkish-white,  or  white,  densely 
hard,  flat,  elevated  tumor,  having  irregular  borders  with 
claw-like  projections  extending  into  the  healthy  skin.  It 
always  has  its  origin  in  an  old  scar,  the  tumor  usually  con- 
forming to  the  outline  of  the  cicatricial  area.  It  develops 
from  stitch  holes,  ear-ring  punctures,  and  scars  resulting 
from  smallpox  and  acne,  and  is  more  frequent  in  negroes 
than  in  others.  Its  treatment  is  not  satisfactory,  since  its 
removal  is  usually  followed  by  return  in  the  scar  left  after 


ADENOMA  241 

the  operation.  Moluscuni  fihrosum  is  an  hypertrophy  of 
the  fibrous  tissue  of  the  skin,  which  hangs  in  folds.  It  need 
not  be  discussed.  Epulis  is  described  as  an  hypertrophy  of 
the  fibrous  tissue.  Fibromata  of  the  other  structures  above 
named  are  general  surgical  conditions  and  will  not  be  con- 
sidered here. 

Lipoma.— Lipoma  is  a  benign  accumulation  of  fat  or 
adipose  tissue,  and  may  be  found  in  any  part  of  the  body. 
Lipomata  are  most  common  under  the  skin,  and  are  of  two 
forms:  (a)  sacculated,  which  means  that  the  tumor  is  cir- 
cumscribed; (b)  diffused,  when  the  abnormal  piling  up  of 
adipose  tissue  is  blended  with  the  normal  fat  surrounding 
the  growth.  Their  only  clinical  significance  is  the  resulting 
deformity.  When  this  is  objectionable,  enucleation  should 
be  made.    Return  is  not  usual. 

Adenoma.— Adenoma  is  a  benign  epithelial  tumor  of  a 
normal  secreting  gland,  composed  of  cells  and  fibrous 
stroma  similar  to  the  structure  of  the  gland  in  which  it 
grows.  It  resembles  carcinoma  in  many  respects,  but  is 
not  malignant,  although  malignant  tumors  of  the  glands, 
or  adeno-sarcomata  are  seen,  and  it  is  often  ciuite  a  difficult 
matter  to  distinguish  between  them,  since  they  are  both  of 
the  epithelial  variety.  There  will  be  considered,  as  having 
particular  interest  to  the  dentist,  three  varieties:  (a)  Se- 
baceous cysts,  commonly  called  "wens,"  result  from  an 
occlusion  of  the  excretory  duct  of  a  sebaceous  gland  (for 
description  see  Cysts),  (b)  Adenoma  of  the  thyroid  gland, 
commonly  known  as  goiter  or  bronchocele,  consists  in  an 
enlargement  of  the  thyroid  gland,  entire  or  (occasionally) 
of  but  one  side.  It  contains  a  colloid  fluid,  in  which  is  found 
cholesterin.  The  fluid  accumulates  from  the  center,  gradu- 
ally destroying  the  gland  structure.  There  are  no  symp- 
toms except  those  due  to  pressure.  These  tumors  are 
not  usually  removed  unless  the  size  is  enormous,  (c)  Ade- 
noma of  the  salivary  glands  develops  from  the  gland  itself, 
and  is  contained  within  its  capsule. 


242  TUMORS   IN   GENERAL 

Neuroma.— Neuroma  is  a  tumor  of  a  nerve  and  may  be 
epiblastic  or  epithelial.  It  develops  along  nerve  trunks, 
especially  the  sensory  nerve;  hence,  the  extreme  pain, 
which  is  frequently  met  with,  and  which  is  sometimes  the 
only  symptom.  The  most  common  variety  of  neuroma  is 
fibro-neuroma,  which  develops  from  the  fibrous  sheath  of 
the  nerve.  Fibro-neuromata  are  quite  frequently  multiple. 
In  two  cases  in  which  dissections  were  made  over  one  thou- 
sand tumors  were  counted  in  each.  They  are  found  on 
the  branches  of  the  nerves  distributed  to  the  tissues  of  the 
face,  esjDecially  of  the  fifth  nerve,  producing  a  most  painful 
atfection  of  the  teeth,  for  which  many  teeth  are  extracted 
with  the  hope  that  the  cause  of  the  pain  will  thus  be  re- 
moved. For  further  consideration  see  the  chapter  on  Neu- 
ralgia. 

Cysts. — A  cyst  is  a  benign  tumor  containing  fluid  or 
semifluid,  surrounded  by  a  capsule.  It  is  due  to  an  ob- 
struction of  the  normal  outlet  of  some  fluid  of  the  body. 
There  are  four  varieties:  (a)  Eetention  cyst,  or  the  ac- 
cumulation, in  a  previously  existing  cavity,  resulting  from 
an  obstruction  of  the  orifice  of  exit;  (b)  tubulo-cyst,  or  a 
dilatation  of  a  duct  or  tube  carrying  fluid,  due  to  obstruc- 
tion; (c)  hydrocele,  or  accumulation  in  a  serous  cavity; 
(d)  gland  cyst.  It  is  the  latter  variety  which  concerns  the 
dentist. 

Gland  or  mucous  cysts  are  due  to  obstruction  to  the  ori- 
fice of  exit  of  the  mucus  coming  from  a  gland  of  the  mucous 
membrane.  They  are  most  frequently  found  on  the  inner 
surface  of  the  lips.  Rarely  they  develop  from  the  gingival 
mucous  membrane,  or  from  the  vault  of  the  mouth,  resem- 
bling in  course  those  found  in  the  antrum.  They  may  spon- 
taneously erupt  and  result  in  a  cure,  although  they  may 
return  after  repair  takes  place,  provided  the  cicatrix  in- 
cludes the  duct.  Obstruction  to  the  ducts  from  the  glands 
of  Nuhn  near  the  tip  of  the  tongue  produces  cysts.  Treat- 
ment consists  in  enucleation  of  the  entire  gland  and  duet. 


NON-INFECTIVE    TUMORS  243 

NON-INFECTIVE  TUMORS  OF  THE  SOFT  TISSUES  OF  THE 

MOUTH 

In  addition  to  the  tumors  of  the  bones  of  the  mouth, 
malignant  growths,  and  tumefactions,  there  remain  the 
tumors  of  the  soft  tissues  of  the  mouth.  They  may  be 
studied  under  the  following  heads: 

[  (a)  Muciparous  Cysts. 
J  (b)   Cysts  from  the  Glands  of  Nuhn. 

^      "^      * '(c)  Echinococcus  Cysts. 

L  (d)  Dermoid  Cysts. 
["  (a)  Hemangioma, 
(2)  Vascular  Tumors  -]    (b)  Lymphangioma. 

I   (c)  Macroglossia. 

r   (a)   Fibromata. 

(b)  Papillomata. 

(c)  Endotheliomata. 
i.  (d)  Adenomata. 


(3)   Solid  Tumors. 


(1)  Cysts 

(a)  Muciparous  cysts  are  found  anywhere  in  the  mu- 
cous membrane  of  the  mouth,  but  probably  most  frequently 
on  the  lips.  They  have  a  bluish,  glossy  appearance  with  a 
lighter  center,  indicating  the  thinness  of  the  sac.  They  are 
small  spherical  masses,  the  margins  of  which  shade  off  into 
the  surrounding  tissues.  When  opened,  the  fluid  will  be 
found  to  be  a  clear  viscid  or  colloid,  of  the  consistency  of 
the  white  of  an  Qgg.  These  cysts  are  the  result  of  obstruc- 
tion of  the  duct  of  a  mucous  gland,  usually  following  an  in- 
jury.   They  are  simple  and  have  no  complications. 

Treatment  consists  in  incision  and  curettement  to  de- 
stroy the  sac,  and  the  use  of  phenol,  after  which  repair 
usually  follows  without  complication. 

(b)  Cysts  from  the  glands  of  Nuhn  are  found  along  the 
sides  of  the  tongue.    They  contain  a  transparent  fluid  and 


244  TUMORS   IN   GENERAL 

may  reach  the  size  of  a  walnut.  They  result  from  obstruc- 
tion of  the  duct  of  one  of  these  glands.  They  are  pale  red, 
with  a  thin  wall.  Treatment  includes  incision,  curettement, 
cauterization,  and,  if  large,  packing.  Repair  is  usually 
uneventful. 

(c)  Echinococcus  cysts  or  hydatids  are  rare.  They 
are  caused  by  the  larva  of  Tenia.  When  found,  they  re- 
semble hydatids  in  the  liver  and  other  structures.  They 
are  always  multiple,  spherical,  harder  than  the  other  varie- 
ties, and  movable  under  the  mucous  membrane.  They 
may  at  the  same  time  be  found  on  other  parts  of  the 
body. 

(d)  Dermoid  cysts  are  the  result  of  an  abnormal  in- 
vagination of  the  first  and  second,  or  the  second  and  the 
third,  gill-arches  or  embryonic  clefts,  as  a  result  of  an  in- 
completely developed  mandible.  They  are  usually  sub- 
dermal,  under  the  floor  of  the  mouth.  They  may  also  be 
found  above  or  below  the  mylohyoid  muscle,  or  attached  to 
the  mandible  or  hyoid  bone,  or  within  the  substance  of  the 
tongue.  Their  size  varies,  biit  they  may  become  as  large 
as  a  baseball.  When  above  the  membranous  floor  of  the 
mouth,  their  growth  encroaches  upon  the  oral  cavity;  if 
below,  they  appear  in  the  form  of  a  double  chin.  They  are 
firm  and  doughy  and  seldom  fluctuate.  They  are  usually  in 
the  median  line,  are  hard,  and  rarely  painful.  The  growth 
is,  as  a  rule,  slow;  but  when  they  grow  rapidly  there  is 
tenderness  or  pain.  The  overlying  skin  is  not  attached  and 
is  otherwise  normal. 

Diagnosis  must  be  made  from  ranula  and  other  cysts 
and  tumors  of  the  tongue. 

Treatment  is  extirpation.  This  is  best  done  through 
a  median  incision  from  the  genial  tubercles  to  the  hyoid 
bone,  separation  of  the  geniohyoid  muscles,  and  removal. 
The  cyst  is  easily  shelled  from  its  capsule.  The  cavity  is 
packed  for  several  days  and  then  permitted  to  close  from 
the  bottom. 


NON-INFECTIVE    TU:\IORS  245 

(2)  Vascular  Tumoes 

In  addition  to  the  cysts  and  other  tumors  above  referred 
to,  there  are  the  following  vessel  tumors  requiring  men- 
tion: (a)  Hemangioma;  (b)  lymphangioma;  (e)  macro- 
glossia. 

(a)  Angiomata  develop  in  the  mucous  membrane  of 
the  mouth,  in  the  tongue,  and  occasionally  along  the  alveo- 
lar process.  In  all  of  these  locations  they  are,  as  a  rule,  not 
large,  and  are  usually  single.  They  have  a  darkened  bluish- 
red  color.  They  are  composed  of  dilated  venules,  from 
which  blood  may  be  squeezed  back  into  the  other  vessels. 
They  are  soft  in  consistency  and  are  usually  congenital. 
When  they  involve  the  cheek,  they  are,  as  a  rule,  much 
larger,  producing  in  some  cases  marked  deformity. 

When  they  are  small  and  on  the  tongue  they  should  be 
let  alone.  If  so  large  as  to  interfere  with  speech,  mastica- 
tion, or  other  faculties,  they  may  be  removed.  The  opera- 
tion is  very  bloody,  and  several  methods  of  procedure  have 
been  practiced.  A  provisional  ligature  about  the  base  of 
the  tongue  is  first  introduced.  The  tumor  is  then  incised, 
curetted  down  to  the  healthy  tissue,  and  sutured  sufficiently 
deep  to  include  all  bleeding  vessels.  Secondary  hemorrhage 
may  follow.  It  is  better  to  pick  up  and  ligate  all  bleeding 
vessels  after  the  provisional  ligature  is  removed,  and  after 
the  sutures  have  been  introduced,  but  before  they  have  been 
tied.  Ignipunctures  by  the  Thiersch  Paquelin  cautery,  al- 
cohol and  hot  water  injections,  have  all  been  successfully 
used  by  various  operators. 

(b)  Lympliangiomata  are  usually  cystic  when  found  in 
the  mouth,  but  may  be  cavernous.  The  cystic  variety  are 
single,  situated  usually  in  the  end  of  the  tongue  or  in  the 
cheek.  The  size  varies,  and  the  outline  is  irregular.  They 
are  congenital,  but  do  not  attract  attention  until  a  child  is 
several  months  old.  They  resemble  retention  cysts  and 
must  be  differentiated  from  them.    Their  content  is  serous. 


246  TIBIORS   IN   GENERAL 

while  that  of  cysts  is  viscid.  A  second  variety  is  the  nodu- 
lar, appearing  on  the  back  of  the  tongue,  as  vesicles  con- 
taining a  turbid  fluid.  The  vesicles  appear  some  months  in 
advance  of  the  roughened  nodular  stage.  The  base  of  the 
vesicles  becomes  indurate,  forming  the  nodules  as  a  result 
of  the  inflammatory  change.  The  primary  cause  is  doubt- 
less an  infection. 

Under  local  anesthesia  the  individual  vesicles  and  nod- 
ules should  be  destroyed  by  curettement,  followed  with  the 
use  of  the  Paquelin  cautery,  or  the  latter  may  be  used  with- 
out curettement.  A  second  ojDeration  may  be  required  to 
destroy  all  the  vesicles. 

(c)  Macroglossia,  formerly  sujDposed  to  be  a  congenital 
hypertrophy,  is  now  considered  as  cavernous  lymphan- 
gioma. The  tongue  is  congenitally  enlarged  and  increases 
in  size  gradually,  soon  protruding  from  the  lips.  The  oral 
cavity  is  finally  filled  and  the  enlargement  shows  externally. 
The  surface  of  the  tongue  may  be  studded  with  nodules  and 
vesicles.  The  lymph  spaces  become  considerable  sinuses, 
containing  serum  or  lymph.  The  connective  tissue  is  hyper- 
trophied. 

Treatment  includes  destruction  of  individual  cysts  with 
the  Paquelin  cautery.  A  large  portion  of  the  tongue  may 
be  removed  by  excision.  Hemorrhage  is  a  serious  compli- 
cation owing  to  the  irregular  and  abundant  blood  supply. 
In  excision,  scissors  should  be  used  instead  of  a  scalpel. 
The  cut  should  include  a  wedge  of  the  center  of  the  tongue. 
The  sides  should  be  adjusted  with  deep  through-and- 
through  sutures,  so  as  to  constrict  the  blood  vessels. 

(3)  Solid  Tumoks 

The  benign  solid  tumors  of  the  mouth  resemble  those 
developing  in  other  parts  of  the  body.  The  most  common 
forms  are:  (a)  Fibromata,  (b)  papillomata,  (c)  endothe- 
liomata,  (d)  adenomata. 

It  is  hardly  necessary  that  an  extended  study  of  these 


NON-INFECTIVE    TUMORS  247 

varieties  of  tumors  be  made,  since  the  dentist  will  require 
only  to  exclude  tliem  from  the  common  forms  of  tumefac- 
tions bearing  more  nearly  upon  Ms  field  of  operation. 

Introductory  to  the  presentation  of  the  subject  of  tu- 
mors of  the  alveolar  process,  it  might  be  well  to  call  atten- 
tion to  the  unsystematic  method  in  ^vhich  the  subject  has 
been  studied. 

Bland-Sutton's  classification  of  tooth  tumors  which  was 
given  to  us  many  years  ago  has  not  been  improved  upon  so 
far  as  embryological  tumors  are  concerned. 

The  classification  used  here,  I  think,  will  make  it  much 
easier  for  the  student  of  oral  surgery  to  grasp  the  differ- 
ential points  between  connective  tissue  and  epithelial  tu- 
mors. It  will  be  observed  that  enlargements  of  the  alveo- 
lar process  that  are  inflammatory  or  infective,  in  that  they 
depend  upon  microorganisms  as  a  cause,  have  not  been  con- 
sidered, and  that  only  the  hypertrophies  or  cystic  condi- 
tions associated  with  the  teeth  are  included. 

This  subject  is  best  presented  by  observing  the  follow- 
ing arrangement : 

Developmental  Tumors  of  the  Teeth. 

Neoplasms  of  the  Alveolar  Soft  Tissues. 

Bone  Tumors  and  Cysts. 

Malignant  Tumors. 

Cysts  and  Tumefactions  from  Developed  Teeth. 


CHAPTER  XXIII 

DEVELOPMENTAL    TUMORS    OF    THE    TEETH 

Neoplasms  that  have  as  their  cause  some  portion  of  the 
teeth  during  embryonic  development  are  not  uncommon. 
The  literature  is  not  extensive,  and  the  classification  given 
by  Bland-Sutton  twenty  years  ago  has  not  been  changed. 
Cysts  and  tumors  in  connection  with  the  teeth  during  their 
development  originate  from  one  or  more  of  the  dental  tis- 
sues of  tooth  germs  during  the  process  of  development. 
They  differ  from  impaction,  in  that  the  tooth  does  not  prop- 
erly develop  and  some  portion  of  the  histological  structure 
is  the  nucleus  for,  and  enters  into  the  formation  of,  a  new 
growth.  They  also  differ  from  tumors  having  their  origin 
about  the  roots  of  matured  teeth. 

The  following  summary  of  odontomata  is  taken  from 
Bloodgood:  In  his  analysis  of  ten  cases,  four  cases  oc- 
curred on  the  upper  jaw;  four  cases  on  the  lower  jaw;  two 
cases  on  the  ethmoid.  The  ages  of  the  patients  varied  from 
six  to  thirty  years;  four  were  under  fifteen  years  of  age, 
six  between  twenty  and  thirty.  The  duration  of  the  tumors 
varied  from  three  months  to  thirteen  years. 

Writers  have  not  agreed  as  to  the  real  cause  of  tooth 
cysts.  Sutton  says:  "Histologically,  an  epithelial  odon- 
tome  consists  of  branching  and  anastomosing  columns  of 
epithelium,  portions  of  which  form  alveoli,  the  cells  occupy- 
ing the  alveoli  varying,  and  the  outer  layer  being  columnar, 
while  the  central  cells  degenerate  and  give  rise  to  a  tissue 
resembling  the  stratum  intermedium  of  an  enamel  organ. 
They  probably  arise  from  persistent  portions  of  the  epi- 
thelium of  enamel  organs." 

248 


TUMORS    OF    THE    TEETH  249 

Dr.  J.  C.  Oliver  says:  "Several  explanations  are  pos- 
sible, for  instance :  First,  misplacement  of  the  dental  germ, 
either  in  reference  to  position  and  depth  in  the  gum  tissue, 
or  in  reference  to  the  axis  of  embryonal  development  and 
embryonal  forceps.  Second,  embryonal  rests.  The  neck 
of  the  j)rimitive  bud  that  springs  from  the  primary  enamel 
germ  for  the  development  of  the  permanent  tooth  may  per- 
sist and  develop  cysts  in  definite  relationship  to  the  crown 
of  a  fairly  well-developed  tooth.  Such  a  process  is  entirely 
analogous  to  the  rest  of  the  ovary  which  is  left  after  the 
infolding  of  the  germinal  epithelium,  and  which  is  responsi- 
ble for  the  cystadenomata  of  the  ovary.  Third,  failure  in 
evolution,  (a)  The  membrane  of  Nasmyth  may  become  un- 
usually thick  and  tough,  and  fail  to  resorb.  This  may  occur 
with  a  normally  placed  follicle,  but  more  particularly  when 
the  axis  is  misplaced  and  it  lies  in  an  oblique,  transverse  or 
reversed  position,  (b)  The  wall  of  the  follicle  is  unusually 
dense  and  resistant,  giving  rise  to  a  similar  series  of 
changes  to  the  above.  A  general  or  partial  jumbling  of 
the  enamel  and  dental  papilla  at  the  time  of  their  formation 
may  take  place.  Fourth,  irritation,  (a)  The  proliferative 
activity  of  the  cells  concerned  in  the  evolution  of  the  teeth, 
by  reason  of  displacement,  does  not  meet  with  the  normal 
juxtaposition  and  arrangement  of  cell  force  and  interaction 
that  are  believed  to  be  requisite  to  the  normal  histologic 
arrangement  of  cells  in  their  development.  This  results  in 
a  proliferative  activity  on  the  part  of  the  cells  of  the  dental 
papilla ;  or,  as  occurred  in  the  three  cases  reported,  and  as 
most  often  occurs,  the  surrounding  periosteal  and  other  con- 
nective tissue  structures  undergo  proliferation.  The  his- 
tologic structure  of  the  tissue  found  in  the  cysts  reported 
is  that  of  giant-celled  sarcoma,  but  is  not  sarcomata.  It  is 
composed  of  connective  tissue,  which  has  reverted  to  an  em- 
bryonal or  granulation  tissue  type  under  the  influence  of 
prolonged  irritation,  (b)  The  mechanical  irritation  by  an 
obliquely  or  transversely  placed  tooth  crowding  into  the  side 


Odontomata. 


250  TUMORS    OF    THE    TEETH 

of  an  alveolar  border  may  certainly  give  rise  to  the  same 
irritative  changes  that  have  just  been  described,  and  may 
also  explain  the  three  cases  reported.  The  interior  wall  of 
the  cyst  shows  typical  granulation  tissue.  This  irritative 
change  is  analogous  to  that  found  around  encysted  bullets 
or  other  foreign  bodies." 

Sutton's  classification  of  developmental  neoplasms  of 
the  teeth  is  as  follows : 

'  1.  Epithelial  (enamel  organ). 

2.  Follicular  (fibrous;  cementous). 

3.  Eadicular   (from  the  root). 

4.  Composite  (from  the  whole  germ). 

(1)  Epithelial  Tumors.— Enamel  organ  tumors  are  de- 
veloped from  the  epithelial  cysts.  They  are  usually  multi- 
locular,  filled  with  mucus,  and  have  a  red  circumferential 
area  resembling  sarcoma.  They  generally  develop  at  from 
eighteen  to  twenty- three  years  of  age,  but  may  appear  at 
any  age.  Their  origin  is  probably  from  persistent  remains 
of  epithelium  of  the  original  enamel  organ. 

(2)  Follicular  Odontomata.— This  variety  of  tooth  tu- 
mor, according  to  Sutton,  appears  in  three  forms.  Unless 
the  successive  stages  are  studied  microscopically,  the  fol- 
licular and  fibrous  forms  and  the  composite  variety  pre- 
sent very  much  the  same  characteristics.  These  tumors  are 
typical  of  the  so-called  dentigerous  cysts.  They  develop 
from  the  permanent  teeth,  usually  the  molars.  The  wall 
is  formed  by  the  expanded  tooth  follicle,  which  is  filled  with 
a  viscid  fluid,  and  in  which  is  found  the  imperfectly  devel- 
oped, loose  and  displaced  tooth.  The  tumors  may  grow  to 
enormous  size,  causing  great  deformity.  This  variety  is 
known  as  fibrous.  The  sac  wall  usually  calcifies.  The  ce- 
mentum  of  the  tooth,  i.  e.,  structure  which  gives  origin  to 
the  cementum  of  the  tooth,  has  to  do  with  the  calcareous 
change  above  mentioned ;  hence,  the  name  sometimes  used, 
cementoma.     Two  or  more  tooth  follicles  may  join  in  the 


FOLLICULAR   ODONTOMATA 


251 


process,  when  it  is  known  as  compound  follicular  odonto- 
mata.  Dozens  of  tooth-like  bodies  have  been  removed  from 
such  a  cavity.    Suppuration  rarely,  if  ever,  occurs. 

Bloodgood  says:  ''Under  the  microscope  one  sees  the 
normal  mucous  membrane  of  the  gum,  then  a  zone  of  con- 
nective tissue,  beneath  which  is  the  circumscribed  tumor. 
The  tumor  is  composed  of  branching  epithelial  alveoli  in 
a  connective  tissue  stroma.  Some  of  the  alveoli  are  cysts 
lined  with  the  typical  basal  adamantine  epithelium.  Other 
alveoli  are  solid  with  cells  showing  the  various  morphologic 
changes  of  the  adamantine  epithelium. ' ' 

Cementous  Follicular  Odontomata. — Certain  tooth  tu- 
mors take  upon  themselves  the  consistency  of  a  tooth,  and 


Fig.  75. 


Fig.  76. 


Odontomata,  or  Enamel  Deposit  on  a  Developed  Tooth.     (Case  of  Dr. 

H.  E.  Friesell.) 

may  be  a  simple  budding  from  the  side  of  a  tooth,  from  the 
root  or  the  crown,  or  the  cementous  growth  may  include 
the  entire  tooth,  leaving  the  crown  projecting  in  only  one 
place  to  identify  it  with  the  particular  tooth. 

Thomas  L.  Gilmer  has  very  ably  presented  this  sub- 
ject and  furnished  pathological  specimens  from  his  own 
practice.  He  may  be  quoted  with  profit,  as  follows: 
''Odontomes  are  rare  in  man.  They  are  more  frequently 
found  in  the  jaws  of  the  horse  and  other  animals,  but  when 
both  those  found  in  man  and  those  found  in  animals  are 
considered,    the    number   is    relatively    small.     Composite 


252  TUMORS    OF    THE    TEETH 

odontomes  are  most  frequently  found  in  the  mandible,  but 
are  not  to  be  excluded  from  the  maxilla,  since  two  of  those 
in  this  report  were  from  the  upper  jaw.  They  seem  to 
belong  to  the  molar  region  of  the  jaws.  The  composite 
odontome,  as  indicated,  is  made  up  of  enamel,  dentine  and 
cementum.  These  tissues  may  be  thrown  together  in  a 
more  or  less  homogeneous  mass,  plus  well-formed  diminu- 
tive teeth,  all  united  by  cementum,  easily  made  out 
macroscopically,  or  the  formation  may  appear  to  the  eye 
only  as  a  conglomerate  mass  with  no  well-marked  tooth 
forms.  This  simple,  homogeneous  mass,  as  observed  by 
the  unaided  eye,  is  transformed  by  magnification  into  a 
complex  tumor  of  regularly  formed  teeth  with  their  roots 
and  canals  all  cemented  into  a  solid  and  compact  body. 

"The  composite  odontome  differs  from  the  ordinary 
dentigerous  cyst  containing  diminutive  teeth  or  dentary 
bodies  in  that  the  dentigerous  cyst  contains  no  cement  sub- 
stance other  than  that  which  covers  the  root  of  the  indi- 
vidual tooth,  when  perfectly  formed  teeth  are  found,  with 
each  little  tooth  or  denticle  separate  and  distinct  from  the 
other;  besides,  there  is  a  well-defined  cyst  wall  and  cyst 
fluid.  In  the  composite  odontomes  there  is  no  cyst  wall  or 
cyst  fluid,  so  far  as  I  have  been  able  to  discover.  The  origin 
of  composite  odontomes  has  not  been  fully  made  out,  but 
it  is  reasonable  to  attribute  them  to  the  same  source  as  that 
of  multilocular  cysts  or  adamantomas,  that  is,  to  unatro- 
phied  remains  of  the  epithelial  cord;  or  possibly  to  extra 
buds  given  off  from  the  epithelial  lamina,  which  have  be- 
come distorted  in  development.  Black  attributes  super- 
numerary teeth  to  additional  buds,  which  buds  he  has  dem- 
onstrated. I  removed  a  remarkable  growth  from  the  right 
side  of  the  lower  jaw  of  a  young  man.  This  odontome  is 
the  most  remarkable  I  have  ever  seen.  It  is  composed  of 
diminutive  teeth  more  or  less  perfectly  develoj)ed,  of  the 
incisor,  cuspid  and  bicuspid  types,  and  large  numbers  of 
denticles  and  enamel  drops,  cemented  together  within  this 


FOLLICULAR   ODONTOMATA  253 

oblong,  crescentic  mass.  The  odontome  measures  antero- 
posteriorly  34  mm.,  bucco-lingually  18  mm.,  from  crown 
rootwise  19  mm.  Measurements  of  the  growth  are  24  mm. 
from  before  backward,  20  mm.  from  side  to  side,  and  14  mm. 
from  above  downward.  From  sec- 
tions of  the  tumor  Dr.  F.  B.  Noyes 
has  made  photomicrographs,  which 
show  most  beautifully  and  perfectly 
the  characteristic  composition  of 
this  class  of  odontomes."  In  the 
report  to  the  Illinois  Society,  Dr. 
Black  said  of  the  histologic  appear- 
ance of  the  sections :    '  *  For  the  pur-    pj^    77 —Odontoma  from 

pose    of    examining   its    structure    I         Which    Section    in    Fig. 
^  1    .       1  ,*,,...  78  WAS  Cut.     (Dr.  Thos. 

sawed  it  through,  halvmg  it  m  an  l.  Gilmer.) 
antero-postero-perpendicular  direction,  and  cut  some  sec- 
tions. I  found  all  the  tissues  of  a  normally  developed  tooth, 
but  in  a  state  of  confusion.  There  is  an  entire  absence  of 
any  proper  pulp  cavity.  The  disposition  or  arrangement 
of  the  tissues  is  peculiar  and  striking.  It  is  as  though  there 
were  a  thousand  teeth,  exceedingly  minute,  growing  as 
close  together  as  they  could  be  crowded,  and  the  interstices 
between  them  filled  up  with  enamel  and  cement.  In  the 
field  of  the  microscope,  with  the  sections  I  have,  we  shall 
often  be  able  to  see  a  number  of  these  diminutive  teeth  at 
a  single  view.  Each  has  its  own  little  pulp  chamber  in  due 
form,  its  own  separate  dentine  and  its  own  enamel  cap,  and 
plastered  in  and  about  and  added  on  to  these  there  is  a 
considerable  amount  of  both  enamel  and  cement  of  very 
irregular  formation.  Many  of  the  pulp  chambers  are  par- 
tially filled  with  calcospherites.  These  also  appear  in  many 
parts  of  the  specimen  in  profusion.  It  is  interesting  to  note 
the  resemblance  of  this  odontome  to  the  normal  structure 
of  the  teeth  of  some  of  the  lower  orders  of  animals,  espe- 
cially some  species  of  fishes,  in  which  there  are  branching 
and  radiating  pulp  cavities." 


254 


TUMORS    OF    THE    TEETH 


(3)  Radicular  Odontomata.— Eadicular  odontomata  dif- 
fer from  the  follicular  in  that  the  crown  of  the  tooth  does 
not  enter  into  the  diverted  process,  as  it  is  comjDosed  of 
unalterable  enamel.     The  dentine  and  cementum  enter  into 


Fig.  78. — ^Microscopic  Section.     (Dr.  Thos.  L.  Gilmer.) 

the  formation  in  varying  proportions.  The  tooth  erupts, 
but  loses  its  identity  in  the  tumor  which  is  attached  to  the 
base.  Tumors  of  this  sort  are  rare,  and  are  seen  more  fre- 
quently in  the  lower  animals. 

(4)  Composite  Odontomata.— These  comprise  a  combi- 
nation of  two  or  all  of  the  tissues  of  the  teeth.     The  ce- 


DIAGNOSIS   OF    ODONTOMATA  255 

mentum,  enamel  and  dentine  may  be  involved.  The  normal 
tooth  structures  are  entirely  displaced  by  the  new  process. 
In  other  regards  they  do  not  differ  from  the  first  three 
varieties. 

Symptoms.— One  of  the  symptoms  of  odontomata  is 
tumefaction,  beginning,  as  a  rule,  from  the  side  of  the  alveo- 
lar process,  increasing  outward  uniformly  in  all  directions, 
or,  if  the  growths  develop  from  a  buccal  root,  enlarging 
inward.  The  growth  is  not  rapid,  requiring  many  months 
to  produce  much  deformity,  but,  as  it  is  progressive,  there 
is  no  limit  to  the  deformity  if  left  unoperated  upon.  Pain 
may  be  severe  and  is  caused  by  the  pressure  upon  the  nor- 
mal nerve  terminals  and  surrounding  structures.  There 
are  no  constitutional  symptoms  from  the  tumor  per  se, 
and  when  present  they  are  the  result  of  involvement  of 
adjacent  vital  tissues. 

Diagnosis.— Broca  says  that  any  new  growth  of  the  jaw 
which  occurs  after  complete  development  of  the  teeth  is 
certainly  not  odontoma.  The  diagnosis  is  very  important. 
No  tumor  beginning  in  the  alveolus  before  maturity  should 
be  removed  until  odontoma  is  excluded.  This  may  be  done 
by  passing  a  sterile  needle  into  the  tumor  at  several  points, 
or  an  exploration  incision  may  be  made  and  the  central 
structure  examined.  The  incision  should  be  made  in  view 
of  radical  operation  in  case  malignancy  is  found.  Having 
this  in  mind,  useless  sacrifice  of  tissue  is  prevented.  Firm 
pressure  upon  some  of  these  tumors  reveals  a  parchment- 
like crackling.  A  most  frequent  error  of  the  general  sur- 
geon who  is  on  the  lookout  for  sarcoma,  exostoma,  etc.,  and 
seldom  sees  a  dentigerous  cyst  or  a  tumor  due  to  non- 
eruption,  is  to  mistake  the  latter  condition  for  the  graver 
one.  In  this  event,  he  makes  a  complete  removal  of  a 
maxilla  or  half  of  the  mandible.  After  the  operation  is 
complete  and  the  tumor  is  incised,  a  tooth  is  found  in  the 
center.  Had  the  true  condition  been  suspected,  the  tumor 
would  have  been  removed,  such  abnormal  process  of  the 


256 


TUMORS    OF    THE    TEETH 


bone  as  was  found  would  have  been  chiseled  away,  and  in  a 
few  weeks  repair  would  have  followed  without  deformity 
or  destruction  of  functional  usefulness  of  the  parts. 

Differential  diagnosis  must  be  made  from  tooth  and 
bone  cysts,  osteoma,  exostosis,  sarcoma,  carcinoma,  actino- 
mycosis, and  the  swellings  associated  with  chronic  bone 
diseases,  such  as  syphilitic  gumma  and  tuberculosis. 


Fig.  79. — Multiple  Ctst  of  Mandible  Caused  by  the  Impaction  op  Two 
Teeth  Resting  at  Right  Angles  to  Each  Other. 

Treatment.— The  treatment  of  the  simple  variety  is  ob- 
vious and  efficacious,  namely,  to  incise  the  cyst  as  early  and 
as  thoroughly  as  possible,  remove  the  impacted  rudiment- 
ary or  fully  grown  tooth,  scrape  away  the  epithelial  lining, 
and  pack  the  cavity  with  suitable  material.  In  some  in- 
stances it  may  become  necessary  to  remove  part  of  the  jaw 
and  of  the  cyst-wall,  in  order  to  gain  access  to  the  cavity. 
Many  surgeons  advise  that  such  operations  be  made  from 
within  the  mouth,  as  often  as  this  is  possible.    While  sur- 


TREATMENT  OF  ODONTOMATA        257 

geons  have  erred  in  making  too  aggressive  operations  in 
cases  of  simple  dentigerous  cyst,  error  lias  also  been  com- 
mitted in  treating  proliferating  cystomata  ineffectively, 
thus  subjecting  the  patient  to  many  operations,  each  with 
its  risk,  when  one  correctly  performed  operation  would 
have  been  sufficient. 

A  woman,  aged  about  fifty  years,  had  a  large  tumor  of 
the  molar  region  which  had  been  removed  two  or  three 
times,  to  be  followed  by  a  return.  Malignancy  was  not  sus- 
pected. An  X-ray  (figure  79)  showed  two  impacted  teeth. 
They  were  removed.  It  was  undoubtedly  a  multilocular  cyst 
and  none  of  the  operations  performed  had  removed  all  of 
the  cyst ;  hence,  the  return. 

As  already  indicated,  the  surgeon  should  regard  the 
incision  into  a  supposed  simple  cyst  as  exploratory,  because 
a  differential  diagnosis  between  a  simple  and  a  proliferat- 
ing cyst,  particularly  in  the  early  period  of  growth,  cannot 
be  made  without  direct  inspection.  The  surgeon  should 
also  prepare  the  patient,  and  be  prepared  himself,  for  the 
more  severe  operation,  in  case  the  growth  should  be  a  multi- 
locular one.  In  fact,  it  would  seem  to  be  a  good  plan,  as 
suggested  by  McLane  Tiffany,  in  all  cases  of  operation 
upon  tumors  of  the  maxilla,  to  incise  the  tumor  first,  in 
order  to  be  absolutely  certain  that  mistake  in  diag-nosis 
may  not  result  in  an  unnecessarily  severe  and  disfiguring 
operation. 


CHAPTER  XXIV 

NEOPLASMS  OF  THE  ALVEOLAE  SOFT  TISSUES,  AND  BONE  TUMOES 

AND    CYSTS 

NEOPLASMS  OF  THE  ALVEOLAR  SOFT  TISSUES 

Independent  of  odontomata  and  osteomata,  other  neo- 
plasms are  fonnd  to  develop  from  the  alveolar  soft  tissues. 

The  most  common  forms  are  the  following:  (a)  Papil- 
loma j  (b)  polypus;  (c)  hypertrophy;  (d)  fibroid  and  mye- 
loid epulis. 

(a)  Papillomata 

Several  forms  of  growth  develop  from  the  gums  and 
occur  as  elongated  papillae  in  the  form  of  little  tufts.  Their 
centers  are  composed  of  mesoblastic  tissue  and  they  have 
a  covering  of  the  thickened  epithelium.  They  are  of  the 
epithelial  type,  and  have  an  irregular  surface  with  a  straw- 
berry appearance.  These  tufts  develop  from  the  gingival 
margin  about  one  or  many  of  the  teeth.  The  cause  is  some 
mechanical  irritant,  such  as  tartar,  etc. 

A  typical  case  was  that  of  a  pregnant  woman,  aged 
twenty  years,  upon  whom  a  radical  operation  was  not  ad- 
visable. The  granulations  were  strawberry  red  and  irregu- 
lar, and  bled  freely  upon  the  least  irritation.  At  several 
points  they  grew  as  high  as  the  crowns  of  the  teeth,  and 
more  than  two-thirds  of  the  teeth  were  included  in  the  area 
of  growth.  Tartar  was  found  throughout  the  lingual  sur- 
faces of  the  teeth. 

Treatment  consisted  in  curetting  the  granulations  back 
to  the  healthy  mucous  membrane.     The  hemorrhage  was 

258 


PAPILLOMATA 


259 


controlled  with  adrenalin  solution,  and  tincture  of  iodin 
was  applied  to  the  wounds.  The  patient  was  seen  twice 
every  week  for  four  or  five  weeks,  when  all  tendency  to 
return  had  been  controlled.  She  remained  well  when  seen 
eight  months  later. 

There  is  a  great  tendency  for  these  papillomata  to  re- 
turn, and  even  in  three  or  four  days  they  have  been  seen 


Papilloma  of  Alveolus. 


to  grow  an  eighth  of  an  inch  at  points  where  it  was  thought 
they  had  been  thoroughly  removed  by  curettement. 
Thorough  removal,  cauterization  and  disinfection  are  essen- 
tial if  return  is  to  be  prevented.  There  is  no  tendency  to- 
ward malignancy. 

Figure  80  illustrates  a  case  of  papillomatous  growth 
of  the  gingival  mucous  membrane  extending  entirely  around 
two  teeth  and  including  a  third  along  the  sides.     It  was 


260 


NEOPLASMS    OF    SOFT    TISSUES 


removed  by  the  use  of  a  curette  under  local  anesthesia  and 
followed  by  the  application  of  commercial  tincture  of  iodin. 
There  was  no  return  in  several  months.  The  surface  was 
strawberry-like  and  bled  under  slight  pressure. 

Figure  81  shows  papillomata   of  the  alveolar  process 
and  resembles  the  case  illustrated  in  figTire  80,  save  that 


Fig.  81. — Papilloma  of  Alveolus. 

its  surface  was  not  granular  except  at  some  points.  Opera- 
tion included  removal  by  the  use  of  the  knife  under  local 
anesthesia.    There  was  no  return  after  several  months. 


(b)  Polypus 

Polypi  of  the  gums  are  seen  quite  frequently  and  resem- 
ble such  growths  in  other  parts  of  the  body.  They  differ 
from  papillomata  in  that  they  are  usually  single,  grow  to 


POLYPUS 


261 


considerable  size,  and  have  a  distinct  pedicle,  while  tumors 
of  the  papillomatous  variety  are  multiple  and  grow  exuber- 
antly and  rapidly. 

These  tumors  vary  from  the  size  of  a  pea  to  a  horse 
chestnut,  and  are  found  on  the  gums  in  the  neighborhood 
of  diseased  teeth.  They  are  said  to  be  caused  chiefly  by 
the  ragged  edge  of  a  carious  tooth,  but  it  is  probable  that 
ptomaines  from  the  operations  of  bacteria  stimulate  papil- 


FiG.  82. — Papilloma  of  Alveolus.     (Case  of  Dr.  C.  B.  Bratt.) 


lomatous  growths  upon  granulating  mucous  surfaces  and 
have  more  to  do  with  their  etiology  than  is  usually  sup- 
posed. The  growths  in  question  exhibit  on  section  large, 
branching  papillae,  covered  with  an  abnormally  thick  layer 
of  squamous  epithelium.  The  polypi  are  purely  local  in 
their  origin  and  are  non-malignant. 

Treatment.— The  treatment  consists  in  removal  under 
a  local  or  general  anesthetic.  A  scalpel  or  scissors  may  be 
used.    There  is  no  tendency  to  return.    If  there  is  retura 


262  NEOPLASMS    OF    SOFT    TISSUES 

however,  the  growth  will  he  from  a  new  point  of  the  gum, 
and  not  at  the  point  of  original  growth. 

Illustrative  Cases.— Figure  84  shows  a  typical  poly- 
pus of  the  process  in  a  girl  of  eight  years.  The  growth 
was  over  the  alveolus  with  a  distinct  pedicle  or  contracted 
base  attached  to  the  lingual  gingival  margin.  The  surface, 
while  slightly  roughened,  did  not  bleed  as  do  papillomata. 
Operation  was  performed  by  severing  the  pedicle  mth  a 


Papilloma  of  Alveolus. 


scalpel  under  a  very  mild  degree  of  chloroform  anesthesia. 
There  has  been  no  return. 

Figure  85  shows  a  second  case  of  polypus  in  a  woman, 
aged  thirty  years.  It  had  been  growing  for  several  years. 
In  physical  appearance  it  was  the  same  as  in  the  preceding 
case.  Operation  was  performed  under  local  anesthesia. 
Hemorrhage,  which  was  quite  severe,  was  controlled  by 
pressure.  Eepair  was  prompt,  and  there  has  been  no  re- 
turn. 

(c)  Hypeeteophy 

Hypertrophy  of  the  soft  tissues  over  the  alveolus,  and 
independent  of  it,  is  a  growth  of  the  connective  tissue  be- 
tween the  bone  and  mucous  membrane. 


HYPERTROPHY 


263 


The  enlargement  is  uniform,  developing  on  both  sides 
of  the  process  and  extending  around  the  teeth.  The  margin 
of  the  growth  is  not  defined,  as  in  the  former  varieties,  but 
disappears  in  the  normal  mucous  membrane.  The  surface 
is  covered  with  normal  mucous  membrane.  There  is  almost 
a  bony  hardness,  resembling  osteoma,  odontoma,  and  ma- 
lignant growths  during  their  early  history.  There  is  little 
if  any  pain  and  no  other  local  or  constitutional  symptoms. 
The  condition  may  be  the  early  stage  of  epulis,  but  the 
cases  operated  on  were  very  different  from  cases  of  this 


Fig.  84. — Polypus  of  Gum. 

condition  under  observation.  The  growths  resemble,  or 
may  be  histologically  identical  with,  fibroid  epulis  as  here- 
tofore understood. 

Treatment.— Treatment  consists  in  removal  of  the 
growths  by  excision.  They  are  not  malignant  and  there  is 
usually  no  return. 

Illustrative  Cases.— Figure  86  shows  a  case  of  hyper- 
trophy of  the  left  upper  alveolar  tissue  in  a  woman  aged 
forty-five  years.  It  had  been  growing  for  eighteen  months. 
The  surface  was  smooth,  uniformly  developed,  and  with- 
ous  symptoms.  Eemoval  was  done  by  cutting  to  the  bone 
on  both  sides.  The  process  was  severed  with  a  circular 
saw  on  a  dental  engine.    The  section  was  below  the  nasal 


264 


NEOPLASMS    OF    SOFT    TISSUES 


and  antral  cavities.  The  bone  was  not  involved.  Repair 
was  prompt  and  there  had  been  no  return  in  two  years, 
when  the  patient  was  last  seen. 

The  second  case  (figure  87)  is  very  similar  to  the 
foregoing.  The  patient  was  about  thirty-five  years  of  age. 
The  enlargement  involved  the  upper  process  from  the 
median  line  to  about  the  first  bicuspid.  The  teeth  had  pre- 
viously been  extracted.     The  operation  was  performed  as 


Fig.  85. — Polypus  of  Gum. 

outlined  in  the  former  case.    Repair  was  prompt,  and  there 
was  no  return. 

(d)  Epulis 

From  the  present-day  viewpoint,  epulis  appears  to  in- 
clude any  variety  of  growth  of  the  alveolar  process  which 
takes  the  form  of  a  distinct  tumor.  The  tumor  generally 
grows  in  connection  with  bone,  does  not  show  metastasis, 
and,  as  a  rule,  does  not  recur  after  removal.  During  the 
early  stages,  unless  a  section  is  examined  microscopically 
to  i^rove  its  histological  structure,  it  is  difficult  to  say 
whether  it  is  a  hyperplasia,  fibroma,  or  sarcoma.  The  age 
of  the  patient  has  little  to  do  with  the  development,  al- 


EPULIS 


265 


though  the  majority  of  cases  have  been  observed  in  young 
manhood. 

Epulis  is  a  connective  tissue  tumor  arising  from  the 
mesoblast.  The  most  recent  authorities  divide  the  so-called 
epulitic  growths  into  myeloid  and  fibroid,  the  former  being 
of  a  spongy  nature,  with  irregular  surfaces.  The  tendency 
is  to  grow  in  every  direction,  and  in  some  instances  to 
carry  the  teeth  along.  The  surface  is  warty,  and  the  color 
conforms  quite  nearly  to  the  normal  mucous  membrane, 
during  early  development ;  later,  however,  the  color  becomes 


Fig.  86. — Hypertrophy  of  Gum. 

a  darker  red  and,  in  cases  that  become  infective  and  sup- 
purative, reparative  patches  of  a  lighter  hue  will  be  found 
over  the  red  surface. 

The  second  class,  or  fibroid  epulis,  is  most  common  upon 
the  mandible.  Fibromata  are  benign  connective  tissue 
growths,  consisting  chiefly  of  fibers  with  cells,  which  become 
more  numerous  in  proportion  to  the  rapidity  with  which 
the  tumor  grows.  The  growth  is  usually  exceedingly  slow. 
They  are  destructive  only  in  so  far  as  they  are  capable  of 
producing  mechanical  injury  by  pressure.  In  some  cases 
they  will  recur  after  removal,  and  in  these  instances  they 
resemble  sarcoma. 


266 


NEOPLASMS    OF    SOFT    TISSUES 


Hard  fibroma  is  a  dense,  tendon-like  formation,  having 
only  a  few  cells  and  fiat  fibers.  It  is  often  encapsulated. 
It  is  seen  in  the  periosteum  particularly  of  the  dental 
alveoli. 

Soft  fibroma  is  of  a  soft  consistency  and  of  a  loose  tex- 
ture. It  is  seen  as  a  non-capsulated  tumor  of  the  skin, 
also  as  a  polyjDus  of  the  nose.  During  the  early  stage  it 
resembles  the  myeloid  type,  but  soon  assumes  a  plum  or 


Fig.  87. — Hypertrophy  of  Gum. 

a  maroon  color.  There  is  a  tendency  to  grow  from  the 
buccal  surface.  There  is  also  a  tendency  to  develop  in  con- 
centric forms,  as  may  be  seen  in  figure  89. 

Hutchinson  made  a  microscopic  study  of  a  case  of  mye- 
loid epulis,  typical  of  myeloid  sarcoma,  with  giant  cells. 
Nodules  of  bone  were  observed  in  the  slide.  It  had  been 
said  that  these  tumors  did  not  ossify,  but  he  found  the  re- 
verse to  be  the  case.  The  plum  color  of  the  tumor  was 
very  characteristic.    A  case  of  epithelial  epulis  in  a  woman 


EPULIS 


267 


aged  fifty-eight,  and  successfully  treated  by  partial  excision 
of  the  maxilla,  is  reported  by  Malloch. 

Diagnosis  must  be  made  from  simple  acute  inflamma- 
tory diseases  that  run  an  acute  course,  from  polypi  that 
have  smooth  surfaces,  from  cysts,  hypertrophies,  exostoses 
of  the  process,  and  malignant  diseases  of  the  bones.  The 
myeloid  variety,  as  a  rule,  has  a  warty  appearance  and 


Fig.  88. — Myeloid  Epulis. 

grows  outward  in  every  direction  from  the  process,  carry- 
ing along  with  it  a  tooth,  or  many  teeth  if  unmolested.  The 
teeth  rest  insecurely  in  a  jelly-like  mass  and  may  easily  be 
extracted.  The  surface,  when  irritated,  bleeds  readily  and 
sometimes  alarmingly.  In  a  recent  case  in  the  author's 
practice,  a  small  portion  was  removed  for  microscopic  ex- 
amination, and  the  hemorrhage  was  so  profuse  as  to  re- 
quire constant  i)i"essure  for  half  an  hour  to  control  it. 
The  treatment  consists  in  early  and  effectual  removal. 


268 


NEOPLASMS    OF    SOFT    TISSUES 


The  teeth  must  not  be  considered,  as  the  growth  usually  in- 
cludes the  process  down  to  the  roots,  as  well  as  the  peri- 
osteum and  mucous  membrane.  The  accompanying  cases 
will  furnish  typical  examples,  as  well  as  outline  the  treat- 
ment, with  results. 

Treatment  for  the  fibroid  variety  consists  in  removal, 
without  destroying  the  bone  to  any  considerable  extent. 
Eepair  follows  and  there  is  no  tendency  to  return. 


Fig.  89. — ^Fibroid  Epulis  Before  Operation. 

Typical  Case  of  Fibroid  Epulis.— In  the  case  illustrated 
in  figures  89  and  90  the  growth  had  a  maroon  color.  A 
tooth  appeared  to  be  the  irritant,  or  the  teeth  that  were 
included  in  the  growth  were  thought  to  be  the  cause  and 
were  removed  by  a  dentist.  The  growth  as  shown  devel- 
oped in  three  months.  It  was  principally  from  the  buccal 
surface  and  had  a  concentric  tendency.  It  w^as  soft  and 
spongy  and  only  slightly  roughened. 


EPULIS 


269 


Operation  consisted  in  the  removal  of  the  growth  clo^\^l 
to  and  including  the  external  half  of  the  process.     One 


Fig.  90. — Fibroid  Epulis  After  Operation. 


Fig.  91. — Chloroma,  Lower  Jaw. 

tooth  back  of  the  tnmor  was  included  and  required  re- 
moval. Repair  was  prompt,  the  patient  remaining  in  the 
hospital  but  three  days.    The  result  is  shown  in  figure  90. 


270  BONE    TUMORS   AND    CYSTS 

Case  of  Chloroma.— Tlie  hypertrophy  began  in  the  gin- 
gival mucous  membrane  throughout  both  maxillary  bones, 
and  extended  from  these  points  uniformly  in  every  direc- 
tion. 

Photos  were  taken  six  months  after  the  onset.  The  pa- 
tient lived  one  year  after  this.  There  was  no  bone  involve- 
ment. Very  little  local  infection  or  abscess  formation  de- 
veloped.    The   metastasis    extended    down    the   neck,    the 


Fig.  92. — Chloroma,  Upper  Jaw. 

glands  being  involved  but  the  skin  not  being  affected.  The 
growth  extended  across  the  roof  of  the  mouth,  and  the  oral 
mucous  membrane  was  universally  hypertrophied,  so  that 
the  patient  could  take  only  liquid  foods  for  several  months 
before  death.  X-ray  treatment  made  no  impression. 
Microscopic  examination  did  not  show  malignancy. 

BONE  TUMORS  AND  CYSTS 

These  may  be  grouped  in  three  classes :  (a)  Exostoses 
or  osteophytes;  (b)  osteomata  or  hyperostoses;  (c)  cysts  of 
bone. 


OSTEOMA  271 

(a)  Exostoses 

Exostoses  or  osteophytes  are  small,  round,  bony  growths 
arising  in  the  periosteum  and  spreading  laterally  as  a  re- 
sult of  inflammatory  or  traumatic  disturbance  of  this  mem- 
brane and  its  attachment  to  the  bone.  They  are  products 
of  the  periosteum,  just  as  reproduced  bone  after  necrosis. 
They  are  composed  of  branching  trabeculae  or  sheaves  filled 
in  with  cellular  connective  tissue  or  spongy  formation. 
They  have  no  clinical  significance,  do  not  cause  death,  and 
should  be  removed  only  when  making  pressure  on  other 
structures  or  when  their  size  demands  an  operation.  En- 
dosteomata  are  the  same  except  that  the  growth  is  from 
the  endosteum  in  the  center  of  bone.  They  will  not  be  con- 
sidered here.  Exostoses  of  the  accessory  sinuses  of  the 
face  are  not  uncommon.  In  the  anterior  or  frontal  sinuses 
they  grow  to  enormous  size.  The  growth  is  outward.  They 
require  removal  when  their  size  produces  deformity.  They 
are  benign. 

(b)  Osteoma 

Osteoma  or  hyperostosis  is  a  new  formation  of  bone  or 
a  growth  including  the  bone  in  general  and  not  circum- 
scribed as  in  exostosis.  The  entire  bone  structure  is  in- 
volved. The  growth,  while  occasionally  circumscribed,  is 
usually  diffused,  including  a  hyperplastic  change  of  the 
cancellous  and  compact  structure  uniformly.  It  may  be 
found  anywhere  in  the  skeleton.  A  form  is  seen  in  the 
alveolar  process,  where  it  is  usually  diffused  and  the  entire 
process  is  involved,  but  occasionally  it  is  localized.  An 
assignable  cause  (i.  e.,  a  specified  irritant)  is  not  always 
obtainable.  Leontiasis  ossea  is  a  typical  disease  of  this 
variety. 

The  accompanying  illustration  shows  the  case  of  a  man 
aged  forty-nine  years,  who  had  an  osteoma.  At  the  time 
of  operation  it  had  encroached  upon  the  antrum,  obstructed 
both  nasal  cavities,  and  had  pressed  upon  the  orbital  floor 


272 


BONE    TUMORS   AND    CYSTS 


so  as  to  force  the  eyeball  practically  out  of  the  orbital  cav- 
ity, throwing  it  entirely  out  of  line  so  as  to  destroy  the 
bifocal  vision.  The  nasal  duct  was  obstructed  on  the  right 
side,  and  there  was  an  abscess  over  the  top  of  the  tumor, 
extending  up  to  the  frontal  bone.     Operation  consisted  in 

making  an  incision 
over  the  top  of  the 
abscess,  which  was 
evacuated,  and  a  week 
later,  under  gen- 
eral anesthetic,  inci- 
sion was  made  from 
above  downward,  par- 
allel with  the  right 
side  of  the  nose,  down 
to  the  bone.  The  peri- 
osteum and  all  the 
soft  tissues  were  then 
lifted  from  the  tumor 
to  its  posterior  side. 
The  bone  was  chiseled 
away  from  the  septum 
and  from  the  maxilla. 
The  growth  had  ex- 
tended back  slightly 
beyond  where  it  was 
removed  by  the  chisel, 
and  this  portion  was 
removed  by  bone-cut- 
ting forceps.     The  ac- 


FiG.  93. — Osteoma  op  Maxilla.  Osteoma 
shown  returned  after  two  years,  growth  ex- 
tending laterally,  occluding  naval  cavities. 
In  consultation  with  Dr.  IM.  Delmar  Ritchie, 
lateral  incision  exposed  bone  filling  up  entire 
nasal  cavities,  encroaching  upon  orbits,  floor 
of  mouth  and  antra,  and  apparently  contin- 
uous with  maxillary  bones,  so  as  to  prevent 
removal.  Hole  was  made  through  center  of 
bone  into  pharynx,  cutting  through  about 
two  inches  of  sohd  bone. 


companying  X- 
ray  (figure  94)  shows  distinctly  the  extent  of  the  tumor, 
with  part  of  the  shadow  extending  beyond  the  facial  line 
made  by  the  bone.  The  faint  shadow  shows  the  porous  con- 
dition of  the  growth.  As  a  rule,  these  tumors  are  very 
hard,  but  this  growth  was  not  so. 


CYST    OF    BONE 


273 


(c)  Cyst  of  Bone 

This  is  a  tumor  beginning  as  a  small  enlargement  of  the 
alveolus,  usually  upon  the  external  surface.  As  a  rule, 
there  is  no  pain  or  other  inflammatory  symptom.  The 
growth  is  gradual,  extending  over  a  period  of  many  months 


Fig.  94. — X-Ray  of  Osteoma  in  Fig.  93. 

or  years.  The  tumor  is  uniform,  its  margins  well  defined. 
The  mucous  membrane  over  the  surface  is  normal,  as  a 
rule,  and  only  becomes  red  if  infection  and  pus  forma- 
tion occur.  The  tumor  may  develop  years  after  teeth  have 
been  removed  and  run  the  same  course  as  other  bone  cysts. 
The  bone  gradually  melts  away  and  the  space  is  occupied 


274  BONE    TUMORS   AND    CYSTS 

by  a  fluid  formation.  The  bone  around  the  margin  is  usu- 
ally elevated,  due  to  the  tendency  of  the  periosteum  that 
is  left  after  the  bone  destruction  to  reproduce  bone.  The 
elevated  margin  recedes,  however,  as  the  cyst  encroaches 
upon  new  bone.  The  external  margin  is  denuded  in  the 
direction  of  the  extension  only,  the  remaining  wall  being 
well-defined  and  composed  of  well-organized  granulation 
tissues. 

Operation  requires  free  incision,  removal  of  denuded 
bone  and  curettement  of  such  portion  of  the  cyst  wall  as 
appears  incapable  of  repair.  The  cavity  should  be  cleansed 
with  pure  alcohol,  and  only  moderately  packed,  to  control 
hemorrhage;  subsequent  packing  should  be  to  prevent  the 
entrance  of  food  only.  The  walls  should  be  permitted  to 
collapse  so  that  the  cavity  may  be  obliterated  as  early  as 
possible.  The  orifice  should  be  kept  open  with  packing  un- 
til the  deeper  portion  of  the  cavity  has  healed.  Eepair 
without  complication  or  return  may  usually  be  expected. 

An  unusual  tumor  developed  in  the  roof  of  the  mouth  in 
a  woman  aged  thirty  years.  It  first  appeared  about  the  cen- 
ter of  the  median  line.  It  had  been  growing  about  two 
years  when  she  asked  for  an  operation.  At  that  time  the 
left  nasal  cavity  and  all  but  the  upper  part  of  the  right 
were  obstructed.  The  tumor  projected  downward,  flush 
with  the  teeth,  and  filled  the  vault  of  the  mouth.  The  con- 
tent was  callous.  Operation  was  done  through  the  roof  of 
the  mouth.    The  bone  was  denuded  at  several  points. 


.CHAPTER    XXV 

maligjStant  tumors  of  the  mouth 

SARCOMA  IN  GENERAL 

Sarcoma  is  a  malignant  growth  wliicli  has  its  origin 
from  the  mesoblast  and  is  composed  of  embryonic  tissue. 
It  develops  in  all  deep  tissues,  the  cells  being  deposited 
within  the  normal  structures,  finally  displacing  and  de- 
stroying them.  Its  name  is  derived  from  its  gross  resem- 
blance to  flesh,  but,  since  a  microscopic  study  has  been 
made,  the  following  distinct  varieties  are  recognized: 

(a)  Round-celled  Sarcoma.— This  variety  is  composed 
of  small  cells,  with  a  little  intercellular  substance,  growing 
very  rapidly.  The  smaller  the  cell,  the  more  rapid  the 
growth.  Round-celled  sarcomata  rapidly  involve  other  tis- 
sues, and  when  enucleated  quickly  recur.  They  develop  at 
all  ages. 

(b)  Spindle-celled  Sarcoma.— -Spindle-celled  sarcomata 
resemble  the  round-celled  variety  in  clinical  history  in  that 
the  large  size  of  the  cell  retards  the  rapidity  of  the  growth. 
The  cells  are  spindle-shaped.  In  these,  as  in  the  round-celled, 
the  fleshy  material  is  found  between  the  cells.  The  cells 
are  occasionally  so  intimately  interwoven  as  to  give  rise 
to  the  belief  that  they  contain  voluntary  muscular  fibers,  but 
this  is  not  correct.  When  the  growth  is  slow,  the  cells  may 
take  on  a  fibrous  change,  when  they  are  known  as  fibro- 
sarcoma. 

(c)  Giant-celled  Sarcoma.— This  is  sometimes  known  as 
myelo-sarcoma.    It  has  as  a  characteristic  large,  round  or 

275 


276  MALIGNANT    TUMORS    OF   THE    MOUTH 

spindle-shaped  cells  containing  many  nuclei.  The  cells  are 
imbedded  in  a  tissue  resembling  red  bone  marrow.  (Mixed- 
cell  sarcoma  means  a  combination  of  any  two  or  all  three 
of  the  above  variety  of  cells.) 

(d)  Melano  Sarcoma.— Melano  sarcoma  is  so  named 
because  the  tumor  is  stained  by  brownish  or  black  pigment. 
It  is  very  malignant,  and,  when  glands  (its  most  common 
location)  affected  by  it  are  removed,  it  invariably  returns 
and  proceeds  to  a  fatal  termination. 

(e)  Alveolar  Sarcoma.— Alveolar  sarcoma  is  so  named 
because  the  cells  assume  the  arrangement  seen  in  carci- 
noma. Microscopic  examination  shows  that  the  cells  are 
separated  by  a  substance  similar  to  that  found  in  other 
varieties  of  sarcoma.  It  is  thought  that  these  cells  have 
their  origin  from  the  endothelial  cells. 

The  terms  osteosarcoma  (bone)  and  gliosarcoma 
(nerve)  merely  locate  the  growths,  and  do  not  mean  that 
they  differ  histologically  from  the  original  varieties. 

Location. — Sarcoma  develops  in  every  tissue  of  the 
body,  bone,  glands,  skin  and  viscera.  It  makes  its  appear- 
ance at  all  ages,  but  most  frequently  between  the  ages  of 
fifteen  and  twenty-five  years.  In  the  skin,  especially  of  the 
face,  it  develops  from  birth-marks  (nevus),  and  several  may 
appear  at  the  same  time  or  in  succession.  The  growth  be- 
gins as  a  nodule  and  is  very  slow  in  its  course,  eventually 
breaking  down  in  an  ulcer,  progressing  by  ulceration  and 
metastatic  involvement  of  deeper  structures  until  it  termi- 
nates fatally. 

The  bones  of  the  face  are  a  common  location  of  the 
trouble.  It  may  begin  in  what  is  known  as  malignant  epulis, 
or  it  may  develop  from  the  center  of  the  bone,  involving 
it  in  its  entirety.  It  has  a  tendency  to  calcification.  Sutton 
states  that  sarcoma  may  develop  from  a  tooth  follicle.  The 
cells  of  sarcoma  of  the  bone  are  always  round  or  spindle- 
shaped.  This  form  of  sarcoma  concerns  the  dentist  most, 
since,  in  its  incipiency,  as  it  develops  from  the  periosteum 


SARCOMA   IX    GENEEAL  277 

of  the  alveolar  process,  it  may  be  uiistakeu  for  simple  tuber- 
culosis or  sypliilitic  periostitis,  or  the  warty  appearance 
which  it  assumes  later  may  be  mistaken  for  the  simple 
granulation  tissue  found  during  repair  from  extraction,  or 
pyorrhea  and  other  inflammatory  conditions  of  the  gums. 

Unless  it  is  a  result  of  trauma,  its  origin  is  not  kno^\TL. 
Park  says  that  it  is  quite  a  common  sequela  of  delayed  bone 
union,  developing  from  the  ends  of  the  bones. 

Symptoms. — Pain  is  most  constant  and  as  the  disease  ad- 
vances becomes  unendurable,  except  under  an  anodyne. 
Fever,  running  a  low  continuous  course,  is  usual,  but  sel- 
dom goes  high,  and  may  be  entirely  absent  during  the  early 
course.  Emaciation  is  rapid.  Untreated,  the  disease  pro- 
gresses to  suppuration  and  ulceration. 

Diagnosis  is  to  be  made  from  syphilis,  tuberculosis  and 
benign  growths.  If  the  growth  is  ulcerative  a  microscopic 
examination  should  be  made  to  confirm  a  suspicion  of  ma- 
lignancy. If  located  where  an  exploratory  incision  can  be 
made  to  secure  a  section,  this  should  be  done,  since  it  is 
highly  important  that  sarcoma,  if  removed  at  all.  should 
be  removed  early.  Tuberculous  enlargements  may  require 
operation,  while  syphilitic  gumma  should  never  be  cut. 

Prognosis  depends  upon  the  date  at  which  the  growth 
is  removed.  If  Cjuite  early,  return  may  not  occur.  In  rap- 
idly growing  tumors,  when  enucleation  of  the  primary  focus 
has  been  effective,  it  is  quite  common  for  a  secondary  de- 
posit to  develop  in  the  brain,  lungs  or  other  viscera,  destroy- 
ing life  in  a  few  months.  So,  if  an  operation  is  to  be  pre- 
ferred, it  must  be  made  early  or  not  at  all. 

Treatment  consists  in  total  and  thorough  extirpation. 
When  a  bone  is  diseased  it  should  be  entirely  removed, 
especially  if  the  growth  is  rapid.  In  one  case,  while  the 
bone  was  not  entirely  removed,  no  return  occurred  until 
five  years  afterward,  and  then  did  not  develop  in  the  bone, 
but  in  the  glands  and  soft  tissues.  This  does  not  argue 
against  extirpation,  for  in  this  case  operation  was  primarily 


278  :\IALIGXAXT    TUMORS    OF   THE    MOUTH 

done  to  remove  an  offensive  ulceration  from  tlie  month,  and 
not  T^itli  the  hope  of  eradicating  the  disease. 

In  sarcoma  of  the  bones  of  the  extremities,  amx^ntation 
should  be  made  at  the  proximal  joint.  In  sarcoma  of  the 
glands,  the  glands  should  be  removed  to  the  deepest  point. 
In  skin  sarcoma,  the  skin,  tumor  and  cellular  tissue  beneath, 
along  with  the  adjacent  lymphatics,  should  be  included  in 
the  mass  removed. 

SARCOMA  OF  THE  MOUTH 

Sarcoma  presents  the  most  formidable  and  rapidly 
growing  of  all  tumors  involving  the  alveolar  process.  Re- 
cent investigations  show  that  sarcoma  is  the  result  of 
trauma,  such  as  injuries  from  extractions,  contusions  or 
blows,  Api^arently  simple  conditions  about  the  teeth  re- 
quiring operation  may  be  followed  by  sarcoma.  The 
growth  is  uniform,  the  course  ra}ad.  the  tumor  in  a  few 
weeks  becoming  many  times  the  size  of  the  bone  itself. 
When  involving  the  mandible,  it  rapidly  involves  the  skin, 
which  breaks  down,  and  as  mixed  infection  occurs  the  dis- 
charge becomes  profuse  and  offensive.  Further  skin  and 
soft  tissue  are  involved.  The  glands  toward  the  clavicle 
are  enlarged  and  become  suppurative  during  later  stages. 

Symptoms.— It  usually  occurs  in  young  manhood  from 
fifteen  to  twenty-five  years.  The  growth  is  rapid  and  pain- 
ful. Temperature  from  99  to  101  degrees  is  usually  found 
before  suppuration,  and  it  may  increase  after  systemic 
toxemia  from  absorption  following  suppuration. 

Diagnosis.— During  the  stages  of  seciuestration  sarcoma 
must  he  diff'erentiated  from  the  various  forms  of  bone  in- 
fection. The  bone  may  be  cast  off,  resembling  periostitis. 
S;^ljhilitic  gummata  resemble  sarcomata  very  much,  except 
that  the  latter  develop  rapidly  and  in  young  manhood,  and 
s^i^hilis  occurs  at  all  ages.  Exostosis  and  osteoma  are  not 
usual] V  confounded  with  sarcoma,  since  thev  are  character- 


CARCINOMA   IN   GENERAL 


279 


ized  by  a  uniform,  jDainless  enlargement  without  suppura- 
tion. Carcinoma  must  also  be  excluded.  It  occurs  in  mid- 
dle life,  and  the  growth  is  slow. 

Treatment.— Early  diagnosis  and  removal  is  vital. 
When  operation  is  not  done  early,  sarcoma  is  best  con- 
trolled with  judiciously  administered  X-ray  treatment,  fol- 
lowed by  the  removal  of  the  tumor  as  soon  as  the  rays  have 
controlled  the  growth.  Several  operations  may  be  required 
during  the  time  the  rays  are  being 
used.  Many  cases  are  cured  in  this 
way  and  all  are  greatly  benefited. 

Illustrative  Case.— The  case  il- 
lustrated in  figure  95  presented  the 
usual  symptoms  of  necrosis  follow- 
ing alveolar  periostitis  extending 
over  a  period  of  several  months. 
No  signs  of  growth  were  present. 
The  sequestrum  was  removed,  and 
a  favorable  prognosis  was  made. 
The  patient  left  the  hospital  in  one 
week.  Four  weeks  later  she  re- 
turned with  an  unmistakable  sar- 
coma. Four  weeks  after  this,  the 
growth  seen  in  the  figure  had  developed.  It  was  inopera- 
ble, since  complete  enucleation  could  not  be  promised.  The 
growth  remained  latent  during  two  months'  serum  treat- 
ment, when  the  patent  withdrew.  At  the  end  of  another 
month  it  began  to  grow  and  she  died  in  four  months. 


Fig.  95. 


Sarcoma  op  Man- 
dible. 


CARCINOMA  IN  GENERAL 


Carcinoma  or  "hard  cancer"  belongs  to  the  epithelial 
group  of  tumors.  Certain  forms  develop  most  frequently 
about  the  face  and  mouth,  and  their  clinical  significance' 
should  be  well  understood  by  the  dentist. 


280 


]\IALIGNANT    TUMOKS    OF    THE    ^lOUTH 


Carcinoma  is  composed  of  epithelial  cells  arranged  in 
concentric  layers  and  contained  in  an  alveolus  formed  by 
a  fibrous  stroma,  with  a  tendency  to  invade  surrounding 
tissues.  In  different  localities  they  have  the  characteristics 
of  the  epithelial  cells  from  which  they  have  their  origin.  In 
these  growths  the  tendency  is  to  harden  even  during  the 
early  course  of  development.     There  is  a  marked  tendency 


Fig.  96. — Sarcoma  of  ]\I.\xilla. 

for  the  proliferating  cells  to  penetrate  the  basement  mem- 
brane and  the  cellular  tissue  about.  "When  subdermal  tis- 
sue is  involved,  the  corium  is  included  in  the  growth.  "\Mien 
the  tumor  is  defined,  the  skin  or  tissue  in  which  it  is  located 
becomes  cpiite  hard  as  a  result  of  inanition:  ulceration  fol- 
lows, upon  which  a  crust  forms,  which  is  shed  and  reformed, 
usually  increased  in  area  because  of  the  extension.  There 
is  no  inflammatory  infiltration,  and  the  disease  is  cpiite 
well  outlined.  The  cells  are  held  together  by  a  cement  ma- 
terial, there  being  no  intercellular  substance,  such  as  is 
found  in  sarcoma.  There  is  no  blood  supply  to  the  central 
portion,  and  for  this  reason  this  portion  undergoes  either 


CARCINOMA    IN    GENERAL  281 

colloid,  fatty  or  myxomatous  degeneration  or  ulceration. 
There  is  a  tendency  to  inflammatory  changes  as  a  result  of 
mixed  infection. 

Metastatic  involvement  of  the  surrounding  tissues 
through  the  lymphatics  and  veins  is  usual,  and  eventually 
along  these  channels  will  be  found  small  tumors  which  may 
extend  in  the  form  of  a  chain  of  nodes  into  the  cavities  of 
the  body.    There  are  three  varieties : 

(a)  Epithelioma. 

(b)  Tubular  carcinoma. 

(c)  Acinous  carcinoma. 

(a)  Epithelioma.— Epitheliomata  comprise  two-fifths 
of  all  malignant  growths.  In  13,824  cases  of  primary  neo- 
plasms reported  by  Williams,  7,297  were  malignant,  352,  or 
4.5  per  cent.,  were  of  the  lips,  and  340  of  the  lower  lip. 
About  the  same  per  cent,  are  found  on  the  tongue.  About 
75  per  cent,  of  epitheliomata  develop  from  the  face  and  lips. 
The  development  begins  in  congenital  defects,  such  as  nevi, 
in  warts  and  scars,  and  these  forms  are  very  malignant. 
They  develop  quite  frequently  on  the  face  in  the  mandible 
and  maxilla,  and  in  other  bones  of  the  face.  They  attack 
the  mammary  glands,  larynx,  esophagus,  stomach,  and,  in 
fact,  every  part  of  the  body  where  flat  epithelium  is  found. 

Lupus  exedens. — Rodent  ulcer,  or  Jacob's  ulcer,  is  an 
epithelioma  of  the  face,  formerly  not  included  in  the  cancer 
group,  but  thought  to  be  a  local  ulcer.  It  begins  as  a  nodu- 
lar condition  of  the  skin,  well  supplied  with  vessels,  eventu- 
ally breaking  down  into  an  irregular,  deeply  scooped-out 
ulcer,  without  elevation  of  the  margin.  It  develops  slowly, 
requiring  from  one  to  twenty  years  to  terminate  fatally. 
There  is  little  tendency  to  metastasis.  There  are  few  or  no 
local  symptoms  and  no  constitutional  disturbance  until 
quite  late  in  the  course  of  the  destruction. 

Treatment  for  skin  epithelioma  is  eradication  by  some 
method.  Many  dermatologists  use  Bougard's  paste.  Ex- 
cision must  be  made  sufficientlv  far  back  from  the  margin 


282 


MALIGNANT    TUIMORS    OF    THE    MOUTH 


of  the  nicer  to  insure  complete  removal,  and  down  deep 
enough  to  include  the  infiltrated  tissue  constituting  the  base 
of  the  ulcer.  The  gap  thus  left  must  be  closed  by  trans- 
ferring skin  from  adjacent  parts.  On  the  face,  especially, 
the  skin  is  quite  adjustable,  and  plastic  operation  is  capa- 
ble of  bridging  over  a  considerable  extent  of  surface. 

(b)  Tubular    Carcinoma.— Tubular    carcinoma    is    that 
variety  which  grows  from  mucous  surfaces  containing  tubu- 


FiG.   97. — Epithelioma   of   Lip   Be- 
fore X-Ray.     (Geo.  C.  Johnston.) 


Fig.  98.- 


-Epithelioma  of  Lip  after 
X-Rat. 


lar  glands.  The  alimentary  canal  below  the  pavement  epi- 
thelium of  the  larynx  is  the  principal  territory  in  which 
it  is  seen.  It  may  develop  in  the  sebaceous  glands  of  the 
skin.  It  has  its  origin  in  the  columnar  epithelium  lining 
the  ducts  leading  from  the  glands.  Owing  to  its  location, 
it  is  of  little  significance  to  the  dentist. 

(c)  Acinous  Carcinoma.— Acinous  carcinoma  develops 
in  such  glands  as  the  salivary,  thyroid,  pancreas,  and  mam- 
mary, and  in  the  ovaries,  testicles  and  prostate.  This 
variety  grows  quite  slowly,  requiring  from  five  to  twelve 
years  to  terminate  fatally.     There  is  little  tendency  to  ul- 


EPITHELIOMA    OP    THE    MOUTH  283 

ceration.  Acinous  carcinoma  develops  late  in  life,  rarely 
being  seen  under  forty  years  of  age.  The  most  common 
form  is  known  as  scirrhus  or  hard  cancer,  usually  in  the 
pyloric  end  of  the  stomach,  in  the  breast,  or  in  the  lower 
alimentary  canal. 

Encephaloid  carcinoma  grows  rapidly,  with  early  ten- 
dency to  ulceration. 

Treatment.— The  treatment  of  all  forms  of  carcinoma  is 
complete  and  early  enucleation  before  infiltration  into  the 
deeper  structures  of  the  body  occurs,  or  all  operation  is 
useless.  Even  in  the  tongue,  stomach,  and  intestines  early 
operation  effectually  removes  the  disease  and  return  may 
never  occur. 

EPITHELIOMA  OF  THE  MOUTH 

Epitheliomata  of  the  tissues  overlying  the  maxilla  and 
mandible  develop  as  a  result  of  some  chronic  irritant.  Bad 
teeth  are  most  frequent  causes.  A  rough  tooth  constantly 
coming  in  contact  with  adjacent  mucous  membrane,  or  ex- 
cessive tartar  and  spiculae  of  bone  in  neglected  mouths  are 
fruitful  causes.  Papillomata,  epulitic  or  other  fibromata, 
when  cauterized  frequently  for  their  removal,  a  proceeding 
too  often  practiced  by  dentists,  may  result  in  malignancy. 
Cases  of  this  character  are  reported. 

Symptoms.— The  growth  is  slow  and  not  painful  until 
it  reaches  considerable  size.  It  is  found  in  middle  or  ad- 
vanced life.  It  involves  neighboring  lymphatics.  The  tu- 
mor, as  it  is  found  in  the  mouth,  is  irregular  and  warty, 
the  normal  mucous  membrane  entirely  disappearing.  Fur- 
ther extension  includes  the  skin.  Suppuration,  as  a  result 
of  mixed  infection,  with  the  usual  constitutional  symptoms, 
must  follow.    It  then  becomes  very  painful. 

Diagnosis.  — Diagnosis  must  be  made  from  sarcoma, 
gumma,  periostitis,  osteomyelitis,  actinomycosis  and  other 
simple  mouth  tumors  and  ulcers.     Sarcoma  involves  the 


284 


MALIGNANT    TUMORS    OF    THE    MOUTH 


entire  bone,  but  the  tendency  is  to  enlarge  outward.  In 
carcinoma  the  growth  extends  under  the  tongue  and  in  every 
direction  uniformly. 

Prognosis.— Prognosis  points  toward  a  fatal  end  unless 
extirpation  is  done  early  and  effectually. 

Treatment.— Treatment  is  enucleation  followed  with 
Eontgen  rays  for  several  months  to  destroy  the  cells  in  the 


Fig.  99. — Epithelioma  of  Cheek. 


deep  structures,  if  any  remain,  and  to  prevent  return  in 
scar  tissue. 

Report  of  Case.— A  warty  growth  was  found  upon  the 
left  side  of  the  mouth,  crowding  the  tongue  in  and  the  cheek 
out,  and  extending  from  the  ramus  to  the  symphysis  of 
the  inferior  maxillary.  The  growth  included  the  upper 
half  of  the  bone.  The  fact  that  a  previous  curettement  of 
the  growth  had  been  made  about  a  year  before  was  conclu- 
sive evidence  of  the  malignancy  of  the  growth.  The  cause, 
as  stated  by  the  patient,  was  an  injection  of  anesthetic 


EPITHELIOMA    OF    THE    MOUTH 


285 


about  two  years  previously,  given  by  a  dentist  before  the 
extraction  of  a  tooth.  It  was  decided  to  remove  the  entire 
left  half  of  the  inferior  maxillary  and  substitute  an  alu- 
minum bridge  in  place  of  bone.  Measurements  were  made 
on  the  well  side,  and  two  sizes  of  bridge  were  made,  so  as  to 
be  prepared  for  emergency. 

Operation. — A  cut  was  made  with  a  scissors  from  the 
ujoper  edge  of  the  lower  lip  down  to  the  symphysis,  and  an- 


FiG.  100. — -Epithelioma  of  Mouth. 

other  free  incision  made  from  the  lower  end  of  this  cut 
along  the  inferior  margin  of  the  jaw%  back  almost  to  the 
facial  artery.  This  flap  was  dissected  from  the  tumor  and 
turned  back.  Two  cuts  were  next  made  through  the  bone, 
one  at  the  symphysis,  and  the  other  at  the  groove  for  the 
facial  artery.  The  bone  thus  severed  was  easily  removed. 
All  evidence  of  infiltration  of  the  tumor  was  dissected  out. 
The  larger  bridge  which  had  been  made  fitted  perfectly, 
except  that  the  ends  were  not  bent  at  quite  the  correct 
angle  to  rest  evenly  against  the  ends  of  the  bone.     Two 


286  MALIGNANT    TUMORS    OF   THE    MOUTH 

holes  had  been  made  in  both  ends  of  the  bridge.  Corre- 
sponding holes  were  made  throngh  the  bone,  the  drill  enter- 
ing from  the  external  surface  and  passing  out  through  the 
bone  (figure  103).  A  strong  silver  wire  was  passed  through 
these  holes  and  through  those  in  the  aluminum  bridge.  The 
ends  of  the  wire  were  twisted  until  the  bridge  rested  snugly 


Fig.  101. — Epithelioma  of  Alveolus.  An  effective  treatment  in  cases  such 
as  this  is  the  u^e  of  an  electric  or  actual  cautery,  when  the  disease  has 
advanced  beA^ond  the  point  of  radical  operation.  This  is  the  usual 
practice  in  cases  of  epithelioma  of  the  os  uteri.  The  practice  is  to  burn  off 
the  warty  growths  as  they  appear  at  various  points  from  time  to  time. 
This  prevents  further  growth,  and  prolongs  the  life  of  the  patient  many 
years,  unless  metastasis  develops,  when  further  use  of  the  cautery  is 
not  advisable. 

against  the  bone.  The  same  procedure  was  carried  out  at 
the  other  end.  The  twisted  ends  of  wire  were  cut  off 
quite  short  and  bent  down  along  the  internal  surface  of 
the  bridge.  The  sublingual  and  buccal  mucous  mem- 
branes were  stitched  together  over  the  bridge  and  the  skin 
wound  closed  from  the  angle  of  the  jaw  to  the  edge  of  the 
lip.  The  wound  healed  by  primary  union,  and  no  comjolica- 
tion  presented  itself.    The  patient  left  the  hosx3ital  on  the 


EPITHELIOMA    OF    THE    MOUTH  287 

fourteenth  day,  practically  well.  He  had  little  pain  during 
the  course  of  repair.  He  could  open  his  teeth  one  and  one- 
eighth  inches,  and  could  close  them  with  enough  force  for 
the  snap  to  be  heard  across  the  room.     During  the  time 


Fig.  102. — Carcinoma  of  Mandible. 


Fig.  103. — Aluminum  Bridgework  as  Substitute. 

from  the  original  operation  to  the  return  of  the  disease 
(five  years)  he  had  very  fair  use  of  his  jaw,  and  was  able 
to  masticate  his  food,  and  even  chew  tobacco,  so  firm  was 
the  fibrous  tissue  and  bony  deposit  between  the  ends  of  the 
bone.  The  aluminum  bridge  became  loose  at  the  end  of 
three  months  and  was  removed. 


CHAPTER    XXVI 

CYSTS    AND    TUMEFACTIONS    FEOM    DEVELOPED    TEETH 

The  subject  of  cysts  and  tumefactions  from  developed 
teeth  includes:  (a)  Impacted  teeth;  (b)  delayed  eruption; 
(c)  cysts  from  the  roots  of  developed  teeth. 

IMPACTION  OF  TEETH 

Occasionally  teeth  fail  to  erupt.  The  process  of  budding 
may  be  in  the  wrong  direction,  and  the  tooth  grows  upward 
or  to  one  side,  or  some  obstruction  may  interfere  with  the 
normal  eruption,  and  instead  of  the  crown's  pushing  its  way 
through  the  alveolus  it  grows  in  the  opposite  direction. 

Discharging  sinuses  from  the  maxilla  or  mandible  are 
not  always  evidence  of  disease  of  the  antrum  or  other 
sinuses,  nor  of  osteomyelitis  or  tuberculous  bone  disease. 
These  sinuses  are  not  infrequently  the  result  of  impacted 
teeth. 

Indeed,  all  sinuses  giving  a  very  chronic  history  asso- 
ciated with  slight,  or  possibly  no,  pain,  extending  over  a 
period  of  years,  are  more  likely  to  be  caused  by  non-erup- 
tion than  by  destructive  bone  diseases. 

In  mouths  where  all  of  the  teeth  have  been  extracted  and 
a  plate  worn,  if  a  tooth  remains  impacted,  the  pressure  of 
the  plate  will  usually  result  in  absorption  of  the  mucous 
membrane  and  the  tooth  will  present  itself  by  the  formation 
of  an  opening. 

Illustrative  Cases.— The  following  cases  are  typical: 

288 


IMPACTION    OF    TEETH  289 

(1)  Mrs.  A.  T.,  aged  forty-nine  years,  liad  suffered 
with  pain  in  the  right  maxilla,  just  external  to  the  ala,  for 
nineteen  years.  There  had  been  no  discharge  for  sixteen 
years,  when  a  small  opening  which  discharged  small  quan- 
tities of  pus  and  serum  was  discovered,  internal  to  the  sec- 
ond incisor.  This  had  remained 
open  for  three  years ;  occasion- 
ally it  would  close  and  be  fol- 
lowed by  pain,  which  continued 
until  spontaneous  eruption  re- 
lieved the  suffering  (figure  104). 
An  effort  to  determine  whether  it  ^^^^  104.-Impacted  Centkai.. 

was  a  case  of  necrosis  or  impaction  resulted  in  a  decision  of 
the  latter  for  the  following  reasons : 

(1)  In  necrosis  a  greater  amount  of  tissue  would  have 
been  involved. 

(2)  The  character  of  discharge  would  have  been  pus  at 
all  times,  usually  of  an  offensive  odor. 

(3)  The  patient  was  uncertain  as  to  the  eruption  or 
extraction  of  the  second  incisor. 

(4)  In  osteomyelitis  or  tuberculous  bone  disease  a 
sinus  would  have  formed  long  before  it  appeared  in  this 
case. 

(5)  Associated  symptoms,  such  as  swelling,  involve- 
ment of  secondary  structures,  as  the  antrum,  would  have 
resulted,  none  of  which  were  ever  present. 

(6)  The  general  health  of  the  patient  would  have  been 
impaired. 

An  operation  under  general  anesthesia  consisted  in  en- 
larging the  opening  in  the  mucous  membrane  along  the 
line  of  the  alveolus.  As  the  sinus  in  the  bone  was  slightly 
back  of  the  alveolus,  the  bone  was  cut  inward  with  a  chisel. 
After  enlarging  the  opening  sufficiently  to  admit  a  pair  of 
bone  forceps,  they  were  entered  with  some  difficulty,  and  a 
tooth  was  dislodged  from  its  abnormal  location.    The  depth 


290      TUMEFACTIONS   FROM   DEVELOPED    TEETH 

of  the  cavity  thus  left  after  the  removal  of  the  tooth  was 
two  inches,  as  determined  by  actual  measurement. 

The  subsequent  history  showed  that  no  foreign  substance 
had  been  allowed  to  remain,  and  the  sinus  was  entirely 
closed  in  a  week.  It  has  remained  so  and  has  been  free 
from  pain  for  four  years. 

(2)  Mrs.  A.,  aged  fifty-four  years,  had  had  her  teeth 
extracted  when  thirty-five  years  old  and  had  worn  a  full 

upper  vulcanite  plate  for  fifteen 
years  with  perfect  comfort.  After 
wearing  a  new  plate  for  several 
weeks,  she  returned  to  the  dentist 
and  accused  him  of  making  the  suc- 
tion cavity  too  large,  dead  bone  re- 
FiG.iOo.-lMPACTED  LATERAL,  ^^-^iting  iu  the  roof  of  her  mouth.  A 

careful  examination  revealed  the  existence  of  a  tooth 
slightly  to  the  center  of  the  oral  vault.  There  was  a  very 
small  sinus ;  the  orifice  was  not  granular,  as  it  would  have 
been  were  dead  bone  present,  and  there  was  but  slight  dis- 
charge. A  probe  came  in  contact  with  a  smooth  hard  sub- 
stance characteristic  of  a  tooth.  An  operation  was  ad- 
vised and  accepted.  A  perfectly  developed  canine  was  re- 
moved. The  wound  promptly  repaired  and  a  malpractice 
suit  was  averted. 

(3)  Another  case  was  that  of  a  woman  aged  twenty- 
four  years,  who  had  been  wearing  a  full  upper  plate  for 
about  two  years.  A  sinus  was  discovered  in  the  roof  of  her 
mouth  slightly  to  the  left.  A  second  sinus  opened  on  the 
labial  aspect  of  the  alveolus.  Upon  introduction,  a  probe 
came  in  contact  with  a  tooth.  Under  somnoform  anesthetic, 
it  was  removed.  Repair  followed  without  complication,  and 
so  little  change  occurred  that  the  plate  used  before  the  oper- 
ation fitted  perfectly  afterward. 

(4)  Miss  B.,  aged  twenty,  had  been  suffering  pain  in 
the  region  of  the  superior  molars  since  her  twelfth  year. 
She  knew  that  her  twelfth-year  molars  had  not  erupted 


IMPACTION    OF    TEETH 


291 


of    the    opinion 
her    sufferino'. 


that    they    had    something 
This    appeared    to    be 


to 


quite 


and  was 
do  with 
evident. 

Operation  was  advised,  and  under  chloroform  an  in- 
cision was  made  from  the  first  molar  backward  along  the 
crest  of  the  alveolus.  The  incision  was  extended  down  to 
the  bone.  The  soft  tissues,  including  periosteum  and  mu- 
cous membrane,  were  dis- 
sected back  from  the  alve- 
olar ridge  so  as  to  permit 
freedom  in  further  opera- 
tion. The  tooth  was 
found  partially  covered 
with  bone.  This  was  chis- 
eled away,  and  the  tooth 
was  pried  from  its  posi- 
tion with  a  bone  elevator. 
The  crown  of  the  tooth 
pointed  directly  forward 
and  rested  against  the 
first  molar  (figure  106).  The  roots  projected  slightly 
downward,  parallel  with  the  long  axis  of  the  alveolus. 

The  operation  on  the  other  side  was  exactly  the  same, 
the  tooth  being  found  in  the  same  position.  The  flaps  were 
adjusted  and  secured  with  catgut  sutures.  Repair  fol- 
lowed without  complication. 

The  case  is  unusual  because  of  the  bilateral  condition, 
the  teeth  being  in  the  same  position  on  each  side. 

(5)  An  interesting  case  of  multiple  malposition  with 
cysts  becoming  suppurative  is  that  of  a  young  man  of 
twenty  years  who  had  had  discharging  sinuses  and  tume- 
factions of  the  right  maxilla  for  eight  years.  A  sinus  led 
into  the  right  cuspid  and  another  into  the  right  upper  mo- 
lar, with  other  sinuses  extending  back  of  the  maxillary  bone 
on  both  sides,  well  into  the  zygomatic  fossae.  The  patient 
had  had  two  operations,  one  in  the  antrum  and  another  for 


Fig.  106. — Impacted  Teeth. 


292      TUMEFACTIONS   FROM   DEVELOPED    TEETH 


necrosis,  but  in  neither  instance  were  the  impacted  teeth 
found  (figures  107  and  109). 

Operation  included  the  removal  of  the  impacted  teeth, 
with  curettement,  and  repair  followed  in  the  course  of  a 
few  weeks,  with  no  further  symptoms  from  the  maxilla. 
The  patient  returned  in  three  months  with  an  enlargement 
over  the  lower  left  second  bicuspid.     This  tooth  had  not 


r 


Fig.  107.  Fig.  108. 

Figs.    107,  108. — Impaction   of  Teeth  with   Abscesses   and  Cysts.     Illus- 
trating case  described  in  text. 

erupted.  An  operation  was  performed  and  this  tooth,  im- 
bedded in  cystic  material,  fully  developed,  was  removed 
after  chiseling  away  sufficient  of  the  external  table. 

The  patient  returned  seven  years  later  with  tumefac- 
tions on  the  external  surface  of  both  angles  of  the  mandible. 
These  enlargements  were  the  size  of  a  silver  quarter  and 
at  least  half  an  inch  outward  from  the  bone.  With  the 
knowledge  that  neither  one  of  the  lower  third  molars  had 
erupted,  and  with  the  experience  that  had  been  furnished 


IMPACTION    OF    TEETH 


293 


by  the  other  teeth,  diagnosis  of  cysts  developing  from 
the  impactions  was  readily  made  out.  Operation  was  per- 
formed, and  the  teeth  were  removed. 

The  cysts  had  become  suppurative  and  offensive  and  re- 
quired irrigation  for   about   three   weeks.     The   cavities, 


Figs.  109,  110,  Hi. 


Fig.  111. 

-Impaction  of  Teeth  with  Abscesses  and  Cysts. 
trating  case  described  in  text. 


Illus- 


which  were  quite  large,  finally  collapsed  and  were  entirely 
obliterated. 

(6)  Figure  112  shows  a  skull  in  the  collection  of  the 
author.  The  third  molar  is  unerupted ;  the  second  bicuspid 
is  clearly  outlined  as  impacted.  This  clearly  illus crates  an 
average  case  and  the  impacted  tooth  would  no  doubt  have 
required  removal  eventually. 


294      TUMEFACTIONS   FROM   DEVELOPED    TEETH 


(7)  Figure  113  shows  an  impacted  lower  third  molar  of 
the  usual  type,  which  required  removal.  This  case  was  as- 
sociated with  considerable  pain  and  stiffness  of  the  muscles 
of  the  jaw,  which  interfered  with  mastication. 

(8)  In  the  case  illustrated  in  figure  114  the  patient 
first  presented  herself  for  extensive  periostitis  of  the  man- 
dible, in  which  the  entire  bone 
was  bare  on  the  left  side,  and 
which  finally  resulted  in  ne- 
crosis, as  may  be  observed  in 
the  lower  part  of  the  figure.  By 
careful  study  of  the  plate,  four 
impacted  teeth  will  be  observed, 
two  in  the  mandible,  the  lower 
third  molars,  and  upper  third 
molar,  as  well  as  the  upper  first 
bicuspid.  All  of  these  teeth  had 
to  be  removed,  as  well  as  consid- 
erable of  the  lower  part  of  the 
body  of  the  mandible,  before  re- 
pair took  place.  Observe  that 
there  are  several  sequestra  on 

the  lower  border  of  the  mandible.     The  patient  recovered 
with  perfect  function  of  the  jaw. 


Fig.  112. — Impacted  Bicuspid 
Found  in  a  Skuul.  Also  shows 
unerupted  upper  third  molar. 


CYSTS  FROM  DELAYED  ERUPTION 


The  teeth  do  not  always  erupt  at  the  usual  time  because 
of  some  obstruction  at  the  point  of  usual  exit  or  because 
of  cystic  or  perverted  develojoment.  In  some  instances  the 
development  is  outward  and  an  enlargement  is  formed, 
often  so  large  as  to  attract  the  attention  of  the  dentist,  who, 
if  he  does  not  suspect  the  real  condition,  will  send  the  pa- 
tient to  a  surgeon.  In  this  way  an  operation  is  too  often 
performed. 

The  principal  diagnostic  point  is  the   absence  of  the 


CYSTS   FROM   DELAYED    ERUPTION  295 

tooth,  when  it  should  have  erupted.  While  there  is  some 
discomfort — even  more  than  is  usual  with  ordinary  erup- 
tion— the  pain  is  never  very  severe.  There  may  be  nervous- 
ness, slight  fever  and  loss  of  appetite,  but  all  symptoms  are 
mild.  No  operation  should  be  done  unless  the  delay  ex 
tends  over  several  months,  or  special  reasons  exist  for  sur- 


FiG.  113.- — Impacted  Lower  Molar. 

gical  interference,  such  as  suppuration,  unusually  large  tu- 
mor, etc.  If  left  undisturbed,  the  teeth  will  make  their  own 
way  through  the  usual  canal. 

A  case  in  point  is  that  of  a  girl  ten  years  old,  who  had 
been  examined  by  dentists  and  doctors  for  a  tumor  over 
the  root  of  the  left  lower  cuspid  (figure  117).  It  was  half 
an  inch  in  circumference  and  almost  as  high,  and  gradually 
increasing  in  size.    Further  examination  revealed  the  same 


296   TUMEFACTIONS  FROM  DEVELOPED  TEETH 

condition  just  beginning  on  the  opposite  side  at  the  same 
point.    During  the  course  of  the  next  six  weeks,  the  cuspids 


Fig.  114. — Four  Impacted  Teeth  in  One  Case. 


above  showed  the  same  tendency  toward  development  out- 
ward. 

Treatment.— It  is  proper  to  permit  the  teeth  to  develop, 
uninterrupted,  until  they  erupt.  When  they  are  not  in 
proper  position,  the  orthodontist  will  be  able  to  correct  de- 
fects and  deformities. 


CYSTS   FROM   ROOTS   OF   DEVELOPED   TEETH     297 

CYSTS  FROM  ROOTS  OF  DEVELOPED  TEETH 

A  more  common  form  of  cyst  develops  from  the  roots 
of  teeth  after  eruption.  One  or  several  teeth  may  be  in- 
cluded. The  roots  of  the  teeth  involved  melt  away,  thus 
destroying  the  blood  and  nerve  supply.  The  growth  is 
usually  upon  the  external  surface  only,  because  there  is 


Fig.  115. — Impacted  Uppee  Molar. 

less  resistance  in  this  direction.  It  is  doubtless  caused  by 
irritation  and  infiltration  at  the  apex,  as  an  apex  cyst, 
following  the  removal  of  a  nerve  and  filling  the  root 
canal.  The  fluid  is  turbid.  The  cavity  is  quite  distinctly 
outlined.  The  apices  of  the  teeth  extend  into  the  open  cav- 
ity and  are  denuded  back  to  the  bony  wall.  When  these 
cysts  develop  in  the  maxilla  adjacent  to  the  antral  floor, 


298      TUMEFACTIONS    FROM   DEVELOPED    TEETH 


Fig.  116. — Impacted 
Centkal. 


this  cavity  is  usually  involved.    In  some  cases  they  become 
suppurative  and  a  diagnosis  is  more  difficult. 

The  case  shown  in  figures  118  and  119  was  that  of  a 
woman  about  thirty-five  years  of  age.  The  lump  had  been 
growing  gradually  for  more  than  two 
years.  The  cavity  contained  a  thick, 
straw-colored  liquid  with  some  shreds. 
The  wall  was  well  defined,  but  irregu- 
lar. The  roots  of  the  teeth  stood  out 
into  the  cavity,  surrounded  by  the  fluid. 
They  were  denuded  back  to  the  bone, 
and  the  entire  external  table  was  de- 
stroyed to  the  gingival  margin.  The 
apices  were  gone,  thus  destroying  the 
blood  and  nerve  supply. 
The  operation  was  done  through  the  mouth,  and  con- 
sisted in  making  an  incision  down  through  the  center  of  the 
tumor  and  evacuating  the  contents  of  the  cyst.  The  teeth 
were  removed  without  difficulty.  Such  portions  of  bone  as 
were  thought  to  be  dead  were  removed.  The  subsequent 
history  was  uneventful;  repair  fol- 
lowed rapidly. 

Figure  120  is  a  case  of  a  young- 
woman,  aged  thirty  years,  who  had 
a  tumor  on  the  external  surface  of 
the  maxilla  immediately  above  the 
lateral  and  cuspid.  The  tumor  was 
about  the  size  of  the  half  of  a  split 
English  walnut.  A  diagnosis  of 
cyst  was  made,  since  there  had  been 
no  inflammatory  symptoms  from 
the  onset  of  the  development  of  the 
tumefaction. 

The  operation  included  an  incision  into  the  tumor 
through  the  buccal  sulcus  of  the  oral  cavity,  going  directly 
into  the  cyst.     The  material  found  Avas  similar  to  that  in 


Fig.    117. — Cyst   from 
Erupting  Tooth. 


CYSTS  FKOM  ROOTS  OF  DEVELOPED  TEETH  299 


the  preceding  case,  being  mucilaginous  and  straw-colored. 
The  roots  of  the  two  teeth  involved  were  found  projecting 
into  the  cavity,  as  may  be  observed  by  looking  at  the  X-ray 
picture.     The  entire  external  bony  wall  and  soft  tissues 


Fig.  118. — Root  Cyst. 


Fig.   119.— Teeth 
FROM  Same   Cyst. 


were  removed  so  as  to  make  the  cavity  of  the  cyst  continu- 
ous with  the  oral  cavity.  The  two  offending  teeth  were 
extracted  and  the  external  bony  and  membranous  walls  were 
removed,  making  the  opening  as 
large  as  possible,  so  as  to  make 
the  oral  cavity  and  the  cyst  cavity 
continuous  with  each  other.  It 
would  not  be  desirable  to  have  a 
cavity  this  size  close  until  the 
architectural  reconstruction  of  the 
bone  took  place  for  fear  there 
might  be  some  accumulation.  The 
cavity  was  packed  in  order  that  it  might  not  close.  There 
were  no  symj^toms  following  the  operation,  as  there  had 
been  none  from  the  beginning,  and  the  cavity  was  obliter- 
ated in  the  course  of  three  months,  the  patient  remaining 
perfectly  well. 


Fig.  120. — Cyst  from  De- 
veloped Tooth. 


CHAPTER  XXVn 

CO]SrGEXITAL     AXD     ACQUIEED     DEFOEMITIES     OF     THE     FACE     AND 
MOUTH    IN    GENERAL 

The  most  common  variety  of  congenital  defect  of  the 
face  is  hare  lip,  and  of  the  month,  cleft  palate.  Defects  of 
the  face  may  vary  from  the  slightest  cleft  or  fissure  of  the 
lip,  not  requiring  operation,  to  a  complete  cleavage  of  the 
face  from  the  mouth  to  the  base  of  the  brain. 

Development  of  the  Face  and  Mouth.— The  first  step  in 
the  formation  of  the  face  is  the  development  of  the  oral 
plate,  the  earliest  indication  of  the  future  mouth.  The  oral 
plate  appears  about  the  twelfth  day  and  is  formed  from  the 
epiblast  and  the  hypoblast,  the  monoblast  being  absent.  It 
is  situated  in  the  ventral  part  of  the  head  of  the  embryo. 
The  oral  plate  being  depressed  by  the  upgrowth  of  sur- 
rounding tissues,  the  produced  fossa  constitutes  the  oral 
pit,  or  stomodeum.  The  oral  plate  now  becomes  the  j)haryn- 
geal  membrane.  The  second  factor  in  the  development  of 
the  face  is  the  appearance  of  the  first  and  second  visceral 
arches,  which  occurs  in  the  third  week.  The  maxillary  proc- 
esses and  mandibular  arches  grow  toward  the  median 
line  of  the  ventral  surface  of  the  body.  The  oral  pit  deepens 
from  the  twenty-first  to  the  twenty-third  day,  and  the  third 
week  it  is  a  fossa.  The  upper  boundary  is  formed  by  the 
nasofrontal  process,  which  is  the  thickening  of  the  ventral 
wall  of  the  forebrain  vesicle.  The  lower  boundary  is 
formed  by  the  mandibular  arches  forming  the  lateral  extent 
of  the  fossa. 

Soon  the  future  nares  are  formed,  foreshadowed  by  the 
development  of  olfactory  plates,  one  on  each  side  of  the 

300 


DEVELOPMENT    OF    THE   FACE 


301 


nasofrontal  process.  These  epithelial  areas  soon  become 
depressions — the  nasal  pits — closely  united  with  the  wall 
of  the  forebrain  vesicle  from  the 
first ;  and  later  they  develop  into  na- 
sal mucous  membrane.  The  naso- 
frontal process  the  fifth  week  be- 
comes globular  processes,  which  con- 
stitute the  inner  boundaries  of  the 
pits.  From  the  nasofrontal  process, 
growing  down  and  forward,  are  the 
lateral  frontal  processes,  forming  the 
lateral  boundaries  of  the  nasal  pits. 
The  nasofrontal  process  is  the  fore- 
runner of  the  intermaxillary  por- 
tion of  the  upper  jaw,  including  the 
corresponding  part  of  the  upper  lip  and  nasal  septum  and 
the  bridge  of  the  nose.  The  lateral  frontal  process  becomes 
the  wing  of  the  nose. 


Fig.  121. — Embryonic  De- 
velopment OF  Face. 
Showing  position  of  the 
intermaxillary  bone  and 
its  relationship  to  the 
alveolar  process  in  uni- 
lateral cleft  palate. 


Fig.  122. — Premaxillary  Bone.  Showing  maxillary  bone  projecting  well 
forward  beyond  the  line  of  the  alveolar  processes  in  a  case  of  double  cleft 
of  the  alveolar  arch  as  well  as  double  cleft  palate. 

Hare  lip  is  a  deformity  resulting  from  failure  of  union 
of  the  nasofrontal  and  maxillary  processes.  The  mandibular 


302  DEFORMITIES   OF   THE   FACE 

arches  do  not  unite  nntil  tlie  thirty-fifth  day.  The  angle 
between  the  maxillary  processes  and  the  mandibular  arches 
corresponds  to  the  angle  of  the  future  mouth.  The  primi- 
tive oral  cavity  is  first  separated  from  the  gut  by  the 
pharyngeal  membrane,  which  ruptures  about  the  fourth 
week.  Soon  after  the  formation  of  the  upper  jaw  the  oral 
surface  presents  two  parallel  ridges.  The  outer  is  larger 
and  develops  into  the  upper  lip;  the  inner  is  smaller  and 
becomes  gum.  The  lip  and  gum  of  the  lower  jaw  are  pro- 
duced in  a  similar  manner.  The  only  demarcation  between 
the  mouth  and  the  nose  is  the  tissue  representing  the  united 
nasofrontal,  lateral  nasal,  and  maxillary  processes. 

The  nares  open  widely  into  the  oral  cavity,  posterior  to 
this  partition.  The  formation  of  the  palate  effects  a  sepa- 
ration between  the  two.  On  the  inner  or  oral  surface  of 
the  upper  jaw,  two  shelf-like  projections  appear,  one  on 
each  side,  which  are  rudiments  of  the  future  palate;  they 
grow  toward  each  other,  the  tongue  projecting  between 
them.  At  the  eighth  Aveek,  union  of  the  two  lateral  halves 
begins  at  the  anterior  ends ;  the  ninth  week,  the  hard  palate 
bones  unite ;  the  eleventh  week,  the  soft  palate  is  developed 
completely  and  unites.  The  uvula  appears  the  latter  half 
of  the  third  month  as  a  small  protuberance  at  the  posterior 
edge  of  the  soft  j^alate. 

From  this  mode  of  formation,  it  can  be  seen  that  the 
cleft  is  never  in  the  median  line,  but  on  one  side  or  both, 
and  when  complete  extends  downward  from  the  anterior 
nares.  When  union  does  not  occur,  the  nasofrontal  or  inter- 
maxillary bone  is  usually  found  projecting  beyond  the  nor- 
mal face  line,  and  when  unilateral,  where  there  is  union  of 
the  bones  on  but  one.  side,  the  free  end  at  the  cleft  is  usu- 
ally projected  beyond  the  normal  side. 

Like  hare  lip,  cleft  palate  is  a  failure  of  the  processes 
or  tubercles  of  early  embryonic  life  to  properly  coalesce. 
The  central  process,  which  forms  the  vomer,  sends  out  a 
coalescing  margin  to  the  right  and  left  to  meet  a  shelf 


p.e.  c. 


m.  t. 


Fig.  123. — Cross  Section  op  Face. 


t.  Tongue 
h.p.  Hard  palate, 
i.m.  Inferior  meatus, 
i.t.  Inferior  turbinal. 
o.m.s.  Opening  of  maxillary  sinus, 
h.  Hiatus  semilunaris. 
b.  Bulla  ethmoidalis. 
a.e.c.  Anterior  ethmoidal  cells. 

f.s.  Frontal  sinus. 
p.e.c.  Posterior  ethmoidal  cells. 


b.  Brain. 
s.s.  Sphenoidal  sinus, 
s.t.  Superior  turbinal. 
s.m.  Superior  meatus, 
m.t.  Margin  to  which  middle  turbinal 
was  attached, 
e.t.  Opening  of  Eustachian  tube, 
n.p.  Naso-pharynx. 
u.  Uvula. 

■ — Copied  from  Onodi's  atlas. 


A  deeper  view  is  here  given  of  the  structures  on  the  outer  wall  of  the  right 
nasal  cavity.  The  middle  turbinal  has  been  entirely  removed  (m.t.  indicates 
its  point  of  separation  from  the  rest  of  the  ethmoid),  so  as  to  show  the  anatomy 
of  that  part  of  the  outer  wall  which  it  covers.  The  section  passes  through  the 
accessory  sinuses  in  the  frontal  bone,  the  ethmoid,  and  the  sphenoid,  and  shows 
the  proximity  of  these  cavities  to  the  brain.  The  openings  of  all  the  accessory 
cavities  can  be  easily  studied ;  particularly  well  brought  out  are  the  relations  of  the 
hiatus  semilunaris,  with  the  infundibulum  opening  into  its  anterior  part,  the 
orifice  of  the  maxillary  sinus  at  its  posterior  extremity,  and  the  opening  of  the 
anterior  ethmoidal  cells  separated  from  it  by  the  swelling  of  the  bulla  ethmoidealis. 
This  plate  shows  how  the  posterior  ethmoidal  cells  and  the  sphenoidal  sinus  open 
into  the  superior  meatus,  the  former  being  below  and  the  latter  above  the  superior 
turbinal.     (Reik.) 


304 


DEFOKMITIES    OF    THE    FACE 


which  is  projected  from  either  side  of  the  maxilhiry  proc- 
ess. By  the  union  of  these  the  floor  of  the  nasal  cavity  is 
formed.  A  failure  to  unite  may  occur  on  both  sides,  when 
there  results  a  complete  cleft;  the  septum  standing  down 
into  the  oral  cavity  furnishes  the  plates  from  either  side, 
which  seldom  grow  beyond  the  lateral  nasal  wall.  The  cleft 
in  such  cases  usually  extends  between  the  maxillary  bones 


Fig.  124. — MuscIjES  of  the  Soft  Palate. 

a.  Line  of  di'vision  of  muscles. 

b.  Line  of  incision. 

c.  Palatine  vessels.     (Bryant.) 

through  the  lip,  causing  combined  bilateral  hare  lip  and 
cleft  palate.  Union  may  take  place  on  one  side  only,  a  uni- 
lateral cleft  remaining.  In  other  instances  the  lips  unite 
and  the  bones  coalesce  to  form  a  perfect  alveolar  ridge, 
leaving  a  naso-oral  cleft.  In  still  other  instances  where  the 
bones  unite  and  only  the  soft  palate  remains  open,  the  ab- 
normal condition  may  be  so  slight  as  to  be  no  more  than  a 
bifid  uvula. 

The  causes  which  have  been  given   as  accounting  for 


CONGENITAL   DEFECTS  305 

these  defects  are  arrested  development  from  malnutrition 
or  sickness,  disease  of  the  mother  during  the  early  part  of 
gestation,  maternal  impressions,  and  heredity.  Indeed, 
it  is  all  speculation,  and  the  pros  and  cons  of  these  various 
theories  have  no  place  here. 

Fifty  per  cent,  of  the  cases  of  hare  lip  have  an  asso- 
ciated cleft  palate.  There  is  one  hare  lip  in  2,500  births 
and  about  one  cleft  palate  in  5,000  births. 

Median  Facial  Cleft.— A  very  rare  case  of  median  facial 
cleft  in  an  infant  twenty-three  days  old  is  reported  by  A. 
Wolfer.  The  lower  lip  was  split  in  the  median  line  into 
two  halves,  which  were  again  connected  by  a  cicatricial 
bridge  in  the  lip  proper.  The  latter,  more  strongly  devel- 
oped in  its  upper  part  and  drawn  toward  the  oral  cavity, 
extended  into  the  median  line  of  the  chin  and  into  the  neck 
down  to  the  suprasternal  fossa,  becoming  narrow  and  flat- 
ter as  it  descended.  The  cicatricial  fissure-  in  the  lip  cor- 
responded to  a  defect  in  the  lower  jaw  itself.  This  con- 
sisted of  two  halves,  which  were  united  by  loose  connective 
tissue  and  ran  downward.  The  movable  median  ends  of  the 
two  halves  of  the  lower  jaw  were  decidedly  thinned  and  nar- 
rowed and  terminated  in  a  rounded  and  flat  extremity. 
More  interesting  yet  was  the  condition  of  the  tongue;  the 
anterior  portion  was  divided  longitudinally  in  two  halves, 
like  the  leaves  of  an  open  book.  The  mobility  of  these  two 
halves  was  much  interfered  with  by  the  adhesion  of  a  me- 
dian cicatrix,  at  the  bottom  of  the  fissure,  to  the  floor  of 
the  mouth.  The  base  of  the  tongue  was  not  split.  It  was, 
therefore,  a  median  cleft  of  the  lower  lip,  involving  the 
lower  jaw  and  the  tongue,  the  lateral  halves  being  held  to- 
gether at  a  distance  by  a  cicatrix  formation. 

Other  Congenital  Defects.— The  various  processes  which 
go  to  form  the  skin  of  the  face  may  fail  to  unite  at  any 
point,  leaving  clefts.  The  frontal  and  lateral  tubercles  may 
fail  to  unite,  leaving  a  cleft  extending  upward  and  outward 
from  the  ala  nasi,  or  a  cleft  may  extend  from  the  angle  of 


306 


DEFOEMITIES    OF    THE    FACE 


the  month.  Clefts  of  the  lower  lip  are  rarely  seen.  They 
may  be  associated  with  cleft  of  the  mandible,  or  it  is  possi- 
ble for  the  cleft  to  inclnde  the  tongne,  as  seen  in  AYolfer's 
case. 

Delayed  closnre  of  any  of  the  clefts  leaves  an  nnsightly 
fissnre  across  the  face,  which  may  be  closed  by  ojieration. 


Fig.  125. — An  Unusual  OppuRrcxiTY  to  View  .^^lx  Adenoid  in  Situ,  Through 

A  Cleft  Palate.     (Reik.) 

The  cut  should  include  the  buccal  mucous  membrane. 
Earely  there  is  an  over-^jroduction  of  tissue,  leaving  a  red 
ridge  along  the  line  of  union  of  the  processes.  This  can 
be  removed  by  operation  and  the  skin  adjusted,  leaving  a 
simple  scar  only.  Sinuses,  dimples  and  tubercles  are  oc- 
casionally seen  and  are  due  to  an  incomplete  coalescence 
of  the  processes  at  the  angles  where  they  meet. 

Acheilia,  or  absence  of  the  lips,  is  seldom  seen,  although 


CONGENITAL   DEFECTS 


307 


it  does  occur,  and  can  be  corrected  by  plastic  operation. 
Astomia  is  absence  of  the  oral  cavity,  and  atresia  the  ab- 
sence of  an  oral  orifice,  though  back  of  the  occlusion  there 
is  an  oral  cavity.  In  the  latter  condition  an  artificial  orifice 
can  be  made.  Microstoma  is  a  congenitally  small  mouth 
usually  due  to  arrest  of  development,  and  macrostoma  is  a 
very  large  mouth,  due  to  a  failure  of  the  lateral  and  man- 


FiG.  126. — Very  Large  Hypertrophied  Tonsils  and  Adenoid,  the  Latter 
Visible  as  It  Hangs  Below  the  Margin  of  the  Soft  Palate.  (Reik.) 


dibular  jDrocesses  to  coalesce.  Colohoma,  or  bucco-orbital 
fissure,  is  a  fissure  extending  from  the  mouth  to  the  eye, 
and  is  due  to  non-coalescence  of  the  superior  and  frontal 
processes.  Plypertrophy,  or  macrocheilia  and  micro- 
cheilia,  may  occur  as  a  congenital  defect  or  from  disease  or 
injury. 

Ectropion  is  an  eversion  or  folding-out  of  the  mucous 
membrane  of  the  eye  or  lips,  and  entropion  a  folcling-in  of 
the  lips  or  margin  of  the  eyelids.    These  conditions  may  be 


t 


308  DEFORMITIES   OF   THE   FACE 

congenital  or  acquired,  the  latter  usually  resulting  from 
burns  or  some  variety  of  injury.  Plastic  operations  make 
wondrous  changes  in  these  cases. 

Case  of  True  Double  Lower  Lip. — Dr.  John  B.  Roberts 
presented  a  patient  upon  whom  he  had  operated  for  the 
removal  of  a  true  second  lower  lip.    The  photograph,  which 

was  taken  before  "operation, 
-.^~-.  showed    the    double    lip    to 

consist  of  a  thick  outer  lip 
i  and  a  thinner  internal  struc- 

ture separated  from  the 
outer  by  a  deep  fossa  lined 
with  mucous  membrane.  In 
the  median  line  of  the  mouth 
the  two  lips  were  fused  to- 
gether at  the  vermilion  bor- 
der and  downward  to  the  at- 
tachment of  the  structure  to 
the  alveolar  portion  of  the 
mandible.  The  inner  lip  was  dissected  from  the  outer  and 
excised.  The  raw  surface  was  then  covered  by  drawing 
flaps  of  mucous  membrane  over  it.  The  patient's  curious 
anomaly  was  corrected,  and  his  appearance  much  improved. 

ACQUIRED  DEFORMITIES  IN  GENERAL 

Acquired  defects  of  the  hard  and  soft  palate  are  found 
and  are  caused  by  traumatisms  and  syphilis. 

Traumatism,  as  a  cause  of  perforation  through  the  pal- 
ate, is  rare,  and  when  it  does  occur  is  usually  followed  by 
repair.  When  repair  does  not  occur,  a  plastic  operation  is 
usually  successful. 

Syphilitic  ulcerations  of  the  palate  very  commonly  ie- 
sult  in  complete  perforation  into  the  nasal  cavity.  An  elon- 
gated orifice  sometimes  results,  resembling  congenital  cleft 
palate.     (See  two  cases  under  Syphilitic  Necrosis.)     Opera- 


FiG.  127. — Congenital  Microstoma. 


ACQUIRED   DEFORMITIES  309 

tions  should  not  be  performed  until  sufficient  time  has  been 
given  for  thorough  specific  medication,  which  may  be 
one  year,  for  large  perforations  diminish  in  size  under 
treatment,  when  union  would  not  follow  a  closure  by 
operation. 


CHAPTER    XXVIII 

HAEE    LIP 

Hare  lip  is  the  most  frequently  occurring  of  all  congeni- 
tal defects  of  the  face. 

Clinical  Varieties. — There  are  four  main  varieties : 
1.  Partial  unilateral;  2.  partial  bilateral;  3.  complete  uni- 
lateral (into  naris) ;  4.  complete  bilateral  (into  nares). 
Rarely  it  may  be  partial  on  one  side  and  complete  on  the 
other. 

Prognosis. — The  prognosis  of  uncomplicated  hare  lip  is 
excellent,  especially  when  the  operation  is  performed  before 
the  end  of  the  first  year.  Owing  to  the  possibilities  for  do- 
ing plastic  adjustment,  as  well  as  the  promptness  with 
which  the  face  repairs  when  adjustment  is  skilfully  made, 
repair  can  be  expected  in  ninety-five  per  cent,  of  opera- 
tions.   A  resultant  scar  is,  of  course,  unavoidable. 

Operation  for  Hare  Lip.— The  operation  for  closure  of 
clefts  of  the  lips  is  known  as  cheilorrhaphy  or  cheiloplasty. 
Of  the  many  operations  that  have  been  described  as  origi- 
nal or  modifications,  only  a  few  can  be  considered  here.  The 
end  sought  in  all  operations  is  to  pare  the  margins  of  the 
cleft,  bring  them  together,  and  hold  them  there  until  union 
has  occurred.  The  principal  difficulty  is  to  avoid  a  notch 
at  the  lip  margin,  and  various  methods  have  been  proposed 
to  overcome  the  difficulty.  Malgaigne's  operation,  shown 
in  figures  131,  132,  133,  consists  in  making  the  incisions 
from  the  margins  of  the  cleft  outward  to  near  the  skin 
line  of  the  lip.  The  flaps  thus  made  are  turned  down  and  the 
free  margins  adjusted.    If  the  flaps  are  too  long  they  may 

310 


OPERATION   FOR   HARE   LIP 


311 


be  trimmed  back  so  as  not  to  project  beyond  the  lip  line  after 
repair  takes  place.    It  is  better  to  allow  some  projections 


Fig.  128. 


Fig.  131. 


liG    129 


Fig.  132. 


Fig.  130.  Fig.  133. 

Figs.  128-130. — Nelaton's  Method.    Figs.  131-133.— Malgaigne's  Method. 

128. — Freshening.  131. — Freshening. 

129. — Wound  after  adjustment  of  lip.       132. — The    hp    on    either    side    is    dis- 
located downward. 
130. — Suture.  133. — Sutures  in  position. 

ratlier  than  to  make  them  even,  for  a  certain  amount  of 
contraction  will  occur  along  the  cicatrix.    Mirault's  operar 


312 


HAEE   LIP 


tion  differs  from  Malgaigne's  only  in  tliat  one  of  the  flaps 
IS  entirely  cut  through,  and  the  notch  filled  in  by  the  re- 


FiG.  134. 


Fig.  137. 


Fig.  135. 


Fig.  138. 


Fig.  1.36. 

Figs.  134-136.— MiEArLx-LANO- 
exbeck's  AIethod. 
134. — Freishening. 
135. — Wound. 
136. — Suture. 


Fig.  139. 

Figs.  137-139. — Operatiox  foe  Bilat- 
eral Hare  Lip. 
137. — Freshenine. 
138.— Wound. 
139.— Suture. 


maining  flap.    Hagerdorn's  operation  requires  the  removal 
of  both  marginal  flaps  do.^Ti  almost  to  the  lower  margin  of 


OPERATION   FOR   HARE   LIP 


313 


the  lip.  On  one  side  an  incision  is  extended  back  into  the 
lip  far  enough  to  make  the  adjustment  neat.  Nelaton's  oper- 
ation, figures  128,  129,  130,  is  for  incomplete  cleft,  and  con- 


FiG.  140. — Bilateral  Incomplete  Hare  Lip. 


Fig.  141. — Result  of  Operation. 


Fig.  142. — Unilateral  Complete 
Hare  Lip. 


314 


HARE   LIP 


sists  in  making  an  arc  incision  tlirough  the  lip,  parallel  with 
the  margin  of  the  cleft.    By  buckling  the  flap  downward  a 

transverse  incision  becomes  a  ver- 
tical one.  Fillebrown  makes  a 
straight  instead  of  a  circular  cut, 
otherwise  his  is  the  same  as  the 
operation  devised  by  Nelaton.  Op- 
eration for  double  hare  lip  is  prac- 
tically a  double  Mirault's  incision, 
the  flaps  removed  being  those  from 
the  intermaxillary  portion,  allowing 
the  outer  flaps  to  be  turned  down, 
as  shown  in  figure  138. 

In   all    operations    for   hare   lip, 

when  much  tension  is  made   upon 

the  flaps  in  making  the  adjustment, 

dissected   away  from  the   bone   far 

In  complete  hare 


Fig.  143. — Bilateral  Com- 
plete Hare  Lip,  with 
Projecting  Intermaxil- 
lary Process. 


the   cheek   should  be 

enough  back  to  permit  free  adjustment. 

lip,  care  must  be  taken  to  freshen  the  anterior  surface  of 


Fig.  144. — Result  After  Hare  Lip 
Operation. 


Fig.  145. — Result  After 
Hare  Lip  Operation. 


the  process  near  the  nasal  orifice,  as  well  as  the  upper  part 
of  the  posterior  surface  of  the  lips  to  insure  union ;  other- 


OPERATION   FOR   HARE    LIP  315 

wise  there  will  remain  a  fistula  from  the  nose  to  the  mouth 
between  the  lip  and  the  alveolar  ridge,  a  condition  not  at 
all  desirable. 

Suture  materials  differ  with  different  operators.  To- 
day horsehair  is  used  for  superficial  suturing  and  silkworm 
gut  for  deep  through-and-through  sutures.  Roe  introduces 
his  sutures  from  beneath  the  lip,  crossing  the  cleft  through 
the  margin  of  the  skin  to  the  opposite  side,  and  not  through 
to  the  surface,  thus  avoiding  suture  scars  in  the  skin. 

Dressings  formerly  used  find  no  place  in  modern  prac- 
tice. The  adhesive  plaster,  gauze  and  collodion  alone  serve 
as  pockets  for  infection  and  can  in  no  way  assist  repair. 
When  adhesive  strips  are  necessary  to  make  traction,  they 
should  cross  the  mouth  below  the  wound  to  the  angle  of  the 
mandible,  as  suggested  by  Ferguson. 


CHAPTER  XXIX 


CLEFT  PALATE 


History.— The  first  recorded  stapliylorrliaphy  was  done 
by  Le  Moneir,  a  French  dentist,  in  1764,  and  Eoux  of  Paris 
improved  the  technic  of  the  operation  and  published  his 
results  in  1819.  Independently  of  Roux,  Warren  of  Boston 
operated  and  published  his  case  in  1820.  This  was  followed 
by  operations  by  Pollock,  Lister  and  Ferguson  in  England, 
and  G-raefe,  Diffenbach  and  others  in  various  parts  of 
Europe.  In  this  country,  Pancoast  and  Gibson  of  Philadel- 
IDhia,  Stevens,  Hassock,  Wells  and  others  did  plastic  oper- 
ations for  the  closure  of  the  hard  and  the  soft  palate. 

Etiology.— Brophy  says:  "The  causes  of  congenital 
cleft  palate  are:  1.  Heredity;  2.  mechanical  force  exerted 
by  lower  jaw  against  the  upper  jaw  in  embryo.  In  congen- 
ital cleft  palate  in  young  infants,  the  full  amount  of  tissue 
is  developed  to  form  a  normal  palate,  and  the  defect  is  due 
to  failure  of  union.  General  debility  of  the  mother  in 
early  months  of  gestation  may  be  a  factor.  Prenatal  im- 
pressions possibly,  but  evidence  not  conclusive." 

Varieties.— The  clinical  varieties  of  cleft  palate  are: 
1.  Incomplete — (a)  bifid  uvula,  (b)  bifid  soft  palate,  (c) 
partial  cleft  of  the  posterior  border  of  the  hard  palate,  and 
(d)  fissure  of  the  alveolar  process  and  anterior  border  of 
the  hard  palate;  2.  complete — (a)  unilateral,  and  (b)  bi- 
lateral ;  3.  complicated  with  hare  lip,  unilateral  or  bilateral. 

Time  of  Operation. — The  time  at  which  operation  should 
be  performed  should  be  determined  by  the  condition  of  the 

316 


ANESTHESIA  317 

patient.  Wolff,  the  German  surgeon,  lias  operated  as  early 
as  two  days  after  birth,  and  Billroth,  Knapper,  Langenbeck 
and  Salzer  have,  from  time  to  time,  been  advocates  of  early 
operation. 

Arguments  in  favor  of  postponement  of  cleft  palate 
operations  are:  First,  the  very  young  do  not  stand  shock 
well ;  second,  they  do  not  stand  the  loss  of  blood  so  well  as 
older  patients;  third,  anesthetics  are  not  taken  with  as 
much  safety  as  by  older  children;  fourth,  the  operation  is 
more  difficult  owing  to  the  smallness  of  the  mouth,  and  the 
after-treatment  cannot  be  carried  out  with  the  same  degree 
of  satisfaction. 

Arguments  in  favor  of  early  operation  are :  First,  as 
long  as  the  cleft  remains  open  the  patient  cannot  be  prop- 
erly nourished,  since  food  passes  into  the  nasal  from  the 
oral  cavity;  and  the  act  of  suckling  is  imperfect  on  account 
of  the  continuity  of  the  mouth  with  the  anterior  nares ;  sec- 
ond, patients  are  more  liable  to  have  respiratory  diseases 
and  may  die  of  bronchitis  or  pneumonia ;  third,  the  peculiar 
twang  so  characteristic  of  this  defect,  when  once  acquired, 
is  almost  never  completely  overcome  by  a  closure  of  the  de- 
fect; fourth,  if  it  is  desirable,  as  suggested  by  Brophy,  to 
approximate  the  maxillae,  this  can  be  done  more  readily  in 
the  very  young. 

Ferguson  says:  "The  younger  the  patient,  the  greater 
the  danger."  Brophy  says:  "The  younger  the  patient,  the 
less  the  shock."  From  the  foregoing  contradictory  state- 
ments from  two  of  the  leading  operators  of  to-day,  any 
operator  may  consider  himself  free  to  use  his  own  judg- 
ment, taking  into  consideration  the  condition  of  the  patient. 
If  a  patient  is  fairly  well  nourished,  the  operation  may  be 
postponed  until  he  is  several  months  old.  It  is  best,  of 
course,  to  operate  before  children  begin  to  talk,  to  avoid, 
as  far  as  possible,  the  nasal  intonation. 

Anesthesia.— Various  operators  use  different  methods 
of  anesthetizing.    Brophy  uses  ether  through  a  nasal  tube, 


318  CLEFT   PALATE 

forcing  the  vapor  through  the  nose  with  a  rubber  ball.  Pro- 
found ether  anesthesia  should  first  be  secured.  This  may 
be  followed  by  the  use  of  Brophy's  method  or  one  of  the 
others  where  an  atomizer  is  used,  or  chloroform  may  be 
used  intermittently  as  the  patient  shows  signs  of  recovery. 
Nitrous  oxid  and  oxygen  must  not  be  disregarded.  These 
are  destined  eventually  to  come  into  more  general  use. 
At  this  time,  however,  they  are  not  used  in  the  general 
hospitals,  partly  because  of  the  habit  of  using  ether  and 
because  of  the  greater  expense,  but  principally  for  reasons 
of  safety.  Nitrous  oxid  is  safe  in  skilled  hands,  but  ether 
can  be  given  by  the  unskilled,  and  a  death  almost  never 
follows  its  use  which  cannot  be  attributed  to  other  causes. 
Mouth  Gag's.— A  self -retaining  mouth  gag  adds  greatly 
to  the  operator's  convenience,  and  greatly  assists  in  expe- 
diting the  operation.  For  this  purpose,  the  instrument 
herewith  shown  was  devised  (figure  147).  It  is  made  like  an 
ordinary  gag,  except  that  it  has  extending  from  the  end 
of  the  upper  arm,  about  the  side  of  the  head,  above  and 
around  the  ears,  a  plate  made  of  malleable  metal,  so  that 
it  can  be  accurately  adjusted  to  the  side  of  the  head  without 
being  tilted  from  the  teeth.  This  is  held  in  position  by  a 
head  band,  which  may  be  an  ordinary  sterilized  gauze  band- 
age. With  this  simple  device,  the  assistant  is  free  to  ren- 
der double  service.  A  self-retaining  tongue  depressor  is 
attached  to  the  gag,  as  shown.  The  tongue  can  be  thrown 
up  to  any  desired  position  by  moving  the  lever,  which  is 
pivoted  on  the  lower  arm  of  the  gag.  The  outer  lever  of 
the  tongue  plate  is  bent  along  the  lower  bar  of  the  gag  to 
near  the  end,  where  it  is  turned  up  at  right  angles,  this  part 
passing  through  an  opening  on  the  lower  arm  of  the  gag. 
It  is  secured  by  a  ratchet  or  thumb-screw,  as  may  be 
desired.  As  the  gag  is  closed,  the  pressure  made  by  the 
tongue  plate  is  relieved,  and  as  it  is  opened,  the  tongue  is 
thrown  up  out  of  the  field  of  operation,  or  it  may  be 
adjusted  as  may  be  desired. 


OPERATIONS  319 

Brophy  uses  a  tubular  mouth  gag,  wliicli  extends  back 
on  the  lower  side  and  acts  as  a  tongue  depressor. 

Whitehead's  mouth  gag  has  been  used  for  many  decades. 

OPERATIONS 

Cleft  palate  closure  is  called  uranoplasty  or  uranor- 
rhaphy when  the  operation  includes  the  bones  that  consti- 
tute the  roof  of  the  mouth,  and  staphyloplasty  or  staphylor- 
rhaphy when  the  defect  to  be  closed  is  confined  to  the  soft 
palate  and  uvula.  The  aim  in  operating  is  to  close  the 
chasm  existing  in  the  roof  of  the  mouth  and  shut  otf  the 
nasal  from  the  oral  cavity.  Many  methods  have  been  de- 
vised for  this  purpose,  but  none  can  be  absolutely  relied 
upon  with  any  degree  of  certainty  that  union  will  take 
place.  It  is  not  usually  a  difficult  matter  to  obtain  sufficient 
tissue  to  close  the  cleft,  but  it  is  quite  another  matter  to  pro- 
cure union.  For  this  reason  the  ingenuity  of  the  surgeon 
has  been  put  to  test  for  many  years,  but  as  satisfactory  an 
operation  as  may  be  procured  in  other  branches  of  surgery 
is  yet  to  be  devised. 

Causes  of  Failure,  as  Outlined  by  Ferguson.— Although 
very  commonly  vomiting,  tearing  out  of  the  stitches,  hemor- 
rhage, swallowing  solid  food,  allowing  the  infant  to  put  its 
fingers  into  its  mouth,  and  various  diseases,  are  recognized 
as  causes  of  failure,  the  chief  causes  are:  (1)  tension,  (2) 
unskilfulness  and  devitalizing  the  tissue  by  bruising,  etc.. 
(3)  unsuitable  local  and  constitutional  conditions,  (4)  fail- 
ure to  select  a  suitable  operation  for  the  case,  and  (5)  poor 
nursing.  Poor  nursing  is  a  fruitful  cause  of  failure.  As  a 
rule,  the  mother  is  the  worst  nurse  to  place  in  charge  of  the 
patient.  She  is  overcome  by  her  sympathy  for  him,  and 
rarely  ever  appreciates  the  necessity  and  importance  of 
surgical  cleanliness.  For  this  reason  the  surgeon  should 
insist  on  having  the  patient  placed  in  a  hospital  where  he 
can  have  full  and  complete  control  of  everything  bearing 
on  his  case. 


320 


CLEFT   PALATE 


The  approximation  of  the  maxiUary  hones  by  wires, 
screws  and  hands  is  recommended  by  operators.  Brown's 
method  is  illustrated  in  the  accompanying  figure. 

Manipulation,  or  forc- 
ing the  bones  together  with 
the  fingers,  daily  for  sev- 
eral months,  is  recom- 
mended in  the  very  young, 
to  diminish  the  width  of 
the  cleft.  All  operations  by 
breaking  the  maxillary 
l)ones  formerly  practiced 
liave,  the  author  believes, 
]ieen  abandoned. 

Position  for  Operation. 
— The  Eose  position  is 
favored  by  many  operators.  It  is  claimed,  first,  that  it  fa- 
cilitates hemostasis  by  compression ;  second,  that  it  favors 
the  ready  outward  flow  of  blood  through  the  nostrils,  mak- 


FiG.  146. — Brown's  Model  Showing 
His  ]Method  of  Approximating 
Maxillary  Bones. 


Fig.  147. — Rose  Position  and  Self-Retaining  Mouth  Gag. 

ing  the  field  of  operation  cleaner — instead  of  the  blood 
going  to  the  stomach  it  remains  in  the  nasal  cavities 
or  is  discharged  through  the  anterior  nares;  third,  it  aids 


OPERATIONS 


321 


anesthesia;  fourth,  it  places  the  head  in  the  best  position 
for  operation,  the  operator  sitting  at  the  head  of  the 
patient,  working  over  the  superior  teeth  (see  figure  147). 

The  Rose  position  is  best  secured  by  the  use  of  the 
head-rest  of  an  ordinary  operating  table,  or  by  an  extra 
head-rest  with  a  body  portion  passed  under  the  patient — 
the  head-piece  being  placed  at  an  angle  of  45  degrees  to 
the  plane  of  the  body, 

Brophy  and  many  other  operators  do  not  place  their 
patients  in  the  Rose  position,  but  on  a  horizontal  table. 


Fig.  149. 
Figs.  148  and  149. — Brophy's  Periosteal  Elevators. 


Fig.  150. — Fillebrown's  Hoe. 

Instruments  for  Cleft  Palate  Operation.— The  following 
is  a  list  of  instruments  required: 
Hemostats  and  sponge  holders. 

Staphylorrhaphy  bistouries,  Langenbeck  or  Goodwillie. 
Toothed  fixation  forceps,  curved  and  straight. 
Scissors,  straight,  curved  and  right  angle. 
Scalpels. 

Needles,  small  curved. 

Needles  on  handles,  eye  at  end  (see  figure  165). 
Hook  and  eye  (see  figure  166). 
Wire  cutter  and  twister. 
Fillebrown's  hoes. 
Brophy's  periosteal  elevators  (3  sizes  and  angles). 


322  CLEFT   PALATE 

Mouth  gag  (see  Rose  position). 

Suture  material:  horsehair,  catgut,  silkworm  gut,  silk, 
silver  wire,  iron  wire  (soft  enameled  copper  wire — Bald- 
win). 

Lead  or  aluminum  plates. 

Varieties.— Operations  for  defects  of  the  roof  of  the 
mouth  may  be  divided  as  follows :. 


Fig.  151. — Cleft  Alveolar  Process. 

(1)  Uranoplasty,  or  upon  the  soft  palate. 

(2)  For  cleft  alveolar  process. 

(3)  For  complete  defects  of  the  hard  palate. 

(4)  For  unilateral  cleft  palate. 

(1)  Uranoplasty. — Under  the  first  head,  where  the  de- 
fect does  not  reach  the  hard  palate,  two  methods  of  opera- 
tion are  practiced:    (a)   The  margin  of  the  tissue  may  be 


OPERATIONS 


323 


split  from  apex  of  cleft  to  the  tip  of  the  uvula.  The  supe- 
rior and  inferior  flaps  readily  unfold,  leaving  sufficient 
raw  surface  for  adjustment,  (b)  The  edges  may  be  pared 
by  using  a  Langenbeck  or  Goodwillie  bistoury. 

Suturing  may  be  done  with  horsehair,  silkworm  gut,  or 
30-day  chromicized  catgut.     Eepair  usually  follows  when 


Fig.  152. — Result  in  Case  Illustrated  in  Fig.  151. 

adjustment  is  good,  and  when  tension  upon  the  sutures  is 
correct. 

(2)  Operation  for  Cleft  Alveolar  Process. — Cleft  of  the 
alveolar  process  may  occur  with  hare  lip  without  cleft 
palate,  but  it  rarely  occurs  alone.  Whether  there  is  or  is 
not  a  cleft  of  the  palate,  the  operation  is  pretty  much  the 
same.  When  the  bones  cannot  be  approximated  by  manip- 
ulation or  the  screw  or  wire  devices,  and  especially  when 


324 


CLEFT   PALATE 


an 


ex- 


the  free  end  of  the  incisive  bone  extends  out  beyond  the 
line  of  the  face,  as  in  the  case  shown  in  figure  122,  the 
method  is  to  fracture  the  bone  into  the  naris  on  the  good 
side. 

The  following  case  is  reported  as  typical  of  this  class 

of  cases: 

Figures  151  and  152  show  a  case  of  single  cleft  palate 

and  hare  lip.  The  cleft  in  the 
bone  was  three-eighths  of 
inch,  and  in  the  lip  one  inch. 
Operation  consisted  in 
tracting  the  third  tooth  from 
the  cleft.  The  alveolar  process 
was  fractured  into  the  right  an- 
terior naris  with  a  chisel, 
through  the  tooth  socket.  The 
intermaxillary  bone  was  then 
forced  around  so  as  to  close  up 
the  cleft.  The  free  ends  of  the 
process  were  freshened,  and  the 
bones  were  held  together  by  wir- 
ing. The  drill  holes  were  made 
back  of  the  second  tooth  from  the 
cleft.    Iron  wire  was  used. 

The  hare  lip  was  operated  on 
eleven  days  after  the  first  operation.  The  wire  was  re- 
moved on  the  twenty-ninth  day.  The  second  picture  was 
taken  on  the  thirtieth  day,  when  the  patient  left  the  hospi- 
tal. No  operation  was  done  on  the  roof  of  the  mouth  since 
the  left  nasal  cavitj^  was  not  open  and  there  was  no  palate 
floor  on  the  other  side.  The  inferior  turbinated  extended 
downward,  forming  a  satisfactory  roof  for  the  mouth. 

(3)  Defects  of  the  Hard  Palate. — All  cases  of  defects  of 
the  hard  palate  are  not  operable,  because  of  the  great  width 
of  the  cleft,  and  prosthetic  devices 'must  be  made  to  meet 
the  conditions. 


Fig.  153.  —  Operation  for 
Cleft  Alveolar  Process. 
Representing  the  method  of 
operating  upon  the  case  illus- 
trated in  Figs.  151  and  152. 
This  is  especially  applicable 
in  cases  of  children  who  have 
arrived  at  such  an  age  as  to 
make  the  adjustment  of  the 
two  maxillary  bones  crossing 
the  line  difficult,  if  not  im- 
possible. 


OPERATIONS 


325 


Operable  cases  may  be  divided  into:  (a)  Gothic  or  high 
arches,  where  abundance  of  tissue  is  formed;  (b)  cases  of 
low  arch,  where  dropping  of  the  soft  tissues  from  the  arch 
does  not  bridge  the  cleft,  and  other  lateral  incisions  are 
necessary. 

In  cases  of  the  first  class  Brophy's,  Baldwin's  and  Fer- 
guson's operations  are  to  be  advised.     In  other  cases  the 


Fig.  154. — Cleft  Palate. 

Langenbeck,  Wolff,  Diffenbach,  or  Davies-Colley  operations 
are  required  to  secure  sufficient  material  to  close  the  defect. 

(4)  Unilateral  Defects. — Lane's,  Lanelongue's,  and  H. 
A.  Ferguson's  operations  are  advised  in  unilateral  defects. 

Technique  in  Operations  for  Bilateral  Complete  Cleft 
Palate.^ — "  The  muco-periosteal  tissues  are  separated  from 
the  hard  palate  in  the  usual  way,  generally  using  Brophy's 
instruments.    With  curved  scissors  the  soft  palate  is  de- 


J.  R  Baldwin,  M.  D.,  Columbus,  Ohio. 


326 


CLEFT   PALATE 


tached  from  tlie  hard  palate  by  the  usual  transverse  cut 
across  the  upper  or  nasal  mucous  membrane.  Before  mak- 
ing this  transverse  cut,  the  edge  of  the  soft  palate  is  split, 
-for  this  purpose  sharp-pointed,  slightly  curved  scissors  be- 
ing used,  and  the  tip  of  the  uvula  caught  with  tissue  forceps. 
The  edge  is  split  back  about  one-eighth  of  an  inch.     (By 


Fig.  155. — Uxiox  of  Entire  Cleft  After  Operation  ox  Case  Illustrated  in 
FicrRE  154.  Photograph  would  indicate  that  union  is  not  complete,  but 
cleft  is  closed  completely. 

the  ordinary  operation  the  edges  of  the  soft  palate  are  de- 
nuded by  cutting  off  a  strip  of  tissue.  This  is  an  unneces- 
sary sacrifice,  and  does  not  give  as  broad  a  surface  of  appo- 
sition, and  in  case  of  failure  there  is  less  tissue  to  work  with 
in  a  second  operation.) 

"In  bringing  the  flaps  together  use  a  small  sharply  curved 
needle    affixed    to    a    handle,    the     handle    being    at    right 


OPERATIONS 


327 


angles  to  the  needle.  Instead  of  an  eye  at  the  tip  of 
the  needle  there  is  a  little  hook.  The  needle  is  passed 
so  that  it  is  entered  about  one-eighth  of  an  inch  from 
the  edge,  is  brought  out  at  the  bottom  of  the  split,  then 
passed  across  to  the  opposite 
side,  where  it  enters  at  the 
bottom  of  the  split  on  that 
side,  and  comes  out  one- 
eighth  of  an  inch  from  the 
edge  of  the  flap.  The  thread, 
or  soft  enameled  copper 
wire  which  I  have  used  of 
late,  is  caught  in  the  hook 
and  the  needle  withdrawn, 
carrying  one  end  of  the 
wire.  The  needle  is  passed 
in  again  at  a  distance  of 
about  one-fourth  of  an  inch 
in  the  same  way,  and  the 
other  end  of  the  wire  is  caught  and  drawn  back.  Both  ends 
of  the  wire  are  now  at  one  side  of  the  fissure,  and  the  loop 
on  the  opposite  side,  thus  making  a  mattress  suture.  One 
after  another  the  necessary  sutures  are  introduced  until  all 
are  in  place,  each  being  caught  by  hemostats  to  prevent  en- 
tanglement of  the  ends.  When  all  are  in  place  the  surfaces 
are  thoroughly  freed  from  blood,  then  approximation  is 
secured  by  perforated  shot.  By  the  splitting  of  the  soft 
palate  the  mattress  stitch  results  in  a  turning  dowmward 
of  the  oral  mucous  membrane,  and  upward  of  the  nasal, 
thus  securing  about  one-quarter  of  an  inch  of  raw  surface 
in  close  apposition.  Lateral  incisions,  if  necessary,  are 
made  close  to  the  alveolar  process  on  each  side  to  take  off 
the  tension. 

' '  Stitches  are  introduced  into  the  tissues  corresponding 
to  the  hard  palate  in  the  same  way,  except  that  here  there 
is  no  splitting  of  the  flap,  but  the  introduction  of  the  stitches 


Fig.   156. — Result  from   Hare   Lip 
Operation. 


328 


CLEFT   PALATE 


is  made  in  such  a  way  that  the  edges  of  the  flaps  are  turned 
downward  so  that  a  broad  surface  of  apposition  is  secured. 

' '  The  stitches  should  be 
removed  in  about  ten  days. 
When  these  cases  are  under 
my  control,  I  operate  on  the 
hare  lip  as  soon  as  the  pa- 
tient is  brought  to  me,  pref- 
erably within  a  few  days 
after  birth.  Operation  is 
made  on  the  cleft  palate 
when  the  child  is  one  year 
old,  so  as  to  have  the  palate 
repaired  before  the  child 
commences  to  talk.  The 
„     ,,  ^  older  the  child  the  easier  the 

Fig.  157. — Method  of  Forming  and 

Adjusting  Flaps  in  Cleft-palate      palate     Operation,      DUt     the 

Operations.    (Usually  practiced  by      ™p,^p  j-ff?      i|.  f       ±i      Hiild  fo 

the  Author.)     Diagram  of  the  hard      ^^^re  QimCUlt  lOr  TllC  CniiQ  10 

palate  showing  the  point  at  which 

section  is  made  along  the  margin  of 

the  cleft  but  within  the  nasal  cavity. 

Section  is  made  from  the  anterior 

margin  of  the  cleft  to  the  posterior 

margin    of    the    hard    palate,    with 

Fillebrown's     hoe,     and     separated 

along    the    margin    with    the    same 

instrument. 

learn     to     enunciate     prop- 
erly. ' ' 

Roe's  method,  which  is  a 
revival  of  Garretson's  op- 
eration (see  page  638,  the 
latter 's  work),  is  described 
as  follows :  1.  Drill  holes 
through  margins  of  cleft 
one-half  inch  apart;  (2) 
introduce  wires  through 
holes;  (3)  sever  soft  tissue 
and     bone     from     alveolar 


Fig.  158. — Method  of  Forming  and 
Adjusting  Flaps  in  Cleft-palate 
Operations.  (Usually  practiced  by 
the  Author.)  Showing  the  usual 
method  of  making  muco-periosteal 
flaps  with  a  periosteotome,  which 
is  shown  in  figure   148. 


OPERATIONS 


329 


process  with  scalpel  and  chisel;  (4)  force  the  palates 
toward  each  other;  (5)  freshen  the  margins  of  the  cleft; 
(6)  hold  bones  and  soft  palate  securely  together  with  the 
wires  previously  introduced. 

Unilateral  Operations.— Ferguson  says:  ''The  operation 
must  be  selected  for  the 
case,  and  not  vice  versa.  To 
meet  this  condition,  I  have 
employed  an  operation  with 
much  success  in  cases  where 
the  roof  of  the  mouth  is  like 
a  Gothic  arch — where  the 
palate  segments  extend  up- 
ward into  the  cleft  in  a  more 
or  less  oblicpie  manner,  and 
where  the  cleft  extends  into 


Fig.  159. — Method  of  Forming  and 
Adjusting  Flaps  in  Cleft-palate 
Operations.  (Usually  practiced  by 
the  Author.)  Showing  the  flaps 
after  sutures  have  been  introduced. 
The  plates  and  deep  sutures  shown 
in  this  figure  are  used  by  Brophy  and 
some  other  operators,  but  they  are 
found  to  be  unnecessary  by  many 
operators,  and  the  author  does  not 
use  plates. 


one  nostril.  Two  muco- 
periosteal  flaps  are  liberated 
— one  from  the  inner  or 
nasal  segment,  and  the  other 
from  the  outer  or  oral  seg- 
ment. These  flajos  are  over- 
lajDped,  bringing  the  two  raw 
surfaces  in  contact.  These  are  held  in  position  by  two  rows 
of  interrupted  silk  sutures.  This  operation  is  suitable  at 
all  ages. 

"The first  muco-i^eriosteal  flap  (figure  162)  is  taken  from 
the  nasal  septum  and  inner  segment  of  the  hard  palate, 
commencing  as  high  in  the  nose  as  possible,  and  liberated 
from  above  downward  to  a  point  where  it  is  hinged  to  the 
hard  palate  along  the  border  of  the  teeth.  The  incision 
should  be  extended  in  the  under  surface  of  this  segment  of 
the  soft  palate  and  u\a.Tla,  so  as  to  cause  the  completed  dis- 
section to  form  one  large  flap  from  the  hard  and  soft 
palates.  The  second  flap  (figure  162)  is  formed  from  the 
outer  segTQent  by  making  an  incision  along  the  teeth  down 


330 


CLEFT   PALATE 


to  the  bone,  and  with  a  peri- 
osteal elevator  detaching  a 
nmco-periosteal  flap  until  it 
is  hinged  by  the  mucous 
membrane  along  the  inner 
border  of  the  bone  segment. 

"The  soft  palate  and 
uvula  segment  on  this  side 
are  then  split  along  the  an- 
terior surface.  The  mucous 
membrane  of  the  first  flap 
faces  downward,  while  that 
of  the  second  flap  faces  up- 
ward, so  that  raw  surface  is 
placed  to  raw  surface,  the 
flaps  being  held  in  position 
hx  two  rows  of  sutures  (fig- 
ure 163).  The  roof  of  the 
mouth  is  thus  converted  into 
a  Xorman  arch. 

"In  all  cases  in  which 
this  operation  was  done,  the 
speech  (if  the  patient  was 
old  enough  to  talk)  was  im- 
proved. In  order  to  benefit 
speech  further,  and  lessen 
the  nasal  twang,  the  patient 
should  either  begin  to  learn  another  language  and  forget 
the  mother  tongue  (Ochsner),  or  be  placed  in  charge  of  a 
teacher  who  has  made  a  special  study  of  this  class  of  cases, 
one,  for  instance,  who  instructs  deaf  and  dumb  children." 
(Owen). 

Lanelongue's  Method. — In  unilateral  cases  Lanelongue 
constructed  a  cjuadrilateral-shaped  flap  proportionate 
to  the  dimensions  of  the  gap  from  the  mucous  mem- 
brane of  the  contiguous  surface  of  the  nasal  septum.     A 


Fig.  160.— The  Three  Steps  In 
Closing  the  Soft  Palate  and 
Practically  the  Same  INIethod 
OF  Closing  the  Hard  Palate. 
Illustrating  Baldwan's  Operation. 


OPERATIONS 


331 


long  horizontal  and  two  short  perpendicular  incisions  out- 
line the  flap,  which  is  then  detached  with  a  thin  periosteo- 
tome  and  reflected  downward,  its  base  remaining  attached 


Fig.  161. — Left  Superior  Maxillary  Bone  with  Associative  Parts,  Il- 
lustrating Surgery  of  the  Palate,  a.  Posterior  border  of  horizontal 
plate  of  left  palate  bone.  b.  Velum  separated  from  muco-periosteum  of 
nasal  surface  of  palate  bone.  c.  Velum  separated  from  the  hard  palate,  and 
the  palate  lengthened  so  as  to  restore  palatal  function,  d.  Periosteum  de- 
nuded from  hard  palate.  E.  Palatal  mucous  membrane,  f.  Bones  denuded 
of  membrane.  G.  Nasal  muco-periosteum.  h.  Position  occupied  by  palate 
before  operation,     i.  Posterior  wall  of  the  pharynx.     (Brophy.) 


Fig.     162. — Ferguson's     Operation 
FOR  Unilateral  Cleft  Palate. 


Fig. 


163. — Ferguson's     Operation 
Completed. 


below  to  the  septum.  The  free  border  of  this  flap  is  then 
joined  to  the  freshened  outer  border  of  the  cleft  with 
sutures.    While  this  ingenious  measure  can  be  wisely  em- 


332 


CLEFT   PALATE 


ployed  as  a  dernier  ressort,  still  it  may  also  be  useful  as  a 
supplementary  step  in  the  other  methods  of  closure. 

Introduction  of  Sutures.— To  use  a  needle  with  an  ordi- 
nary needle-holder  requires  a  very  small  needle  and  skilful 
manipulations,  and  much  time  is  consumed.  The  cervix 
needles,  which  have  the  eye  near  the  point,  and  the  end  bent 
at  right  angles  to  the  staff,  answer  quite  well  through  the 
uvula,  but  are  most  difficult  to  handle  between  the  bony 
clefts.     The  usual  staphylorrhaphy  needle  is  bent  at  right 


Fig.  164. — Author's  Method  of  Introducing  Sutures. 

angles  to  the  staff,  with  a  very  slight  curve  of  the  point 
back  toward  the  handle. 

To  overcome  the  difficulties,  the  needle  herewith  illus- 
trated was  devised  (figure  165).  It  has  a  curve  which 
brings  the  point  back  toward  the  handle,  the  curve  being 
just  great  enough  to  make  the  puncture  back  sufficiently 
far  from  the  edge  of  the  flap.  The  instrument  shown  here 
(figure  166)  is  necessary  to  complete  the  introduction  of 
the  suture  skilfully.  It  has  a  ring  on  one  end,  bent  at  right 
angles  to  the  staff  ^vith  an  opening  large  enough  to  admit 
the  threaded  needle.  On  the  other  end  is  a  hook.  The 
needle,  after  being  loaded  with  the  desired  suture  material, 
is  passed  through  back  of  the  flap  into  the  nasal  cavity. 


OPERATIONS 


333 


It  is  then  pushed  through  the  flap  from  the  nasal  into  the 
oral  cavity.  The  ring  end  of  the  instrument  containing  the 
hook  and  ring  above  described  is  pressed  against  the  flap  to 
support  it  and  prevent  laceration.  After  the  needle  and 
suture  pass  through  the  flap,  the  hook  is  made  to  engage 
the  suture  on  the  side  of  the  needle  away  from  the  staff 
(figure  164-B),  and  with  traction  the  free  end  is  drawn 
through  into  the  oral  cavity  as  the  needle  is  pushed  back 
into  the  nasal  cavity  (C).  The  needle,  with  the  thread  still 
in  position,  is  turned  around  to  the  opposite  side,  and  passed 


Fig.  165. — Opjginal  Curved  Needle. 


Fig.  166. — Hook  and  Eye. 


^ 


through  the  flap  as  above  described  (D).  As  the  thread 
is  hooked  up  on  the  inside  of  the  needle,  the  free  end  on 
the  same  side  is  let  go,  and  the  one  on  the  opposite  side  held 
— otherwise  the  needle  would  be  unthreaded.  The  hook  is 
again  passed  around  the  suture  external  to  the  needle,  as 
before  (E),  and  as  the  thread  is  drawn  through  into  the 
oral  cavity,  the  needle  is  pushed  back  into  the  nasal  cavity 
and  drawn  out  between  the  flaps  unthreaded.  This  method 
permits  the  introduction  of  sutures  at  the  extreme  anterior 
angle.  It  is  done  quickly,  and  no  undue  violence  is  done  to 
the  flaps.  An  important  detail  is  that  the  hook  must  be 
passed  around  the  suture  on  the  side  of  the  needle  next 
the  staff,  on  both  sides,  or  when  it  is  withdrawn,  instead  of 
its  unthreading  itself,  it  remains  threaded  and  the  two  ends 
are  drawn  through  the  flaps  on  the  two  sides  of  the  cleft 
(F).  The  thread  may  be  drawn  from  the  internal  side  of 
the  needle,  on  both  sides,  and  the  steps  are  just  the  same. 


CHAPTER    XXX 

DISEASES   OF   THE    MAXILLAEY   AND   OTHEE    SINUSES 

ANATOMY 

The  sinuses  accessory  to  the  nasal  cavity  are  the  maxil- 
lary sinuses,  the  frontal  sinuses,  the  ethmoid  cells,  and  the 
cavities  of  the  body  of  the  sphenoid. 

The  mucous  membrane  which  lines  the  nasal  cavity, 
known  as  the  Schneiderian  membrane,  is  continuous 
through  the  various  foramina  of  entrance  into  these  cavi- 
ties. The  same  membrane  is  continuous  through  the  pos- 
terior nares  over  and  around  the  soft  palate,  becoming  the 
mucous  membrane  of  the  oral  cavity,  the  difference  between 
the  membranes  being  in  the  variety  of  epithelium.  The  oral 
cavity,  except  the  dorsal  surface  of  the  tongue,  is  lined  with 
stratified  epithelium,  while  the  nose  is  lined  with  pavement, 
columnar  and  ciliated,  and  the  upper  part  of  the  pharvnx 
with  columnar  ciliated  epithelium. 

The  maxilla  is  one  of  the  most  important  bones  of  the 
face  from  a  surgical  point  of  view,  and  to  the  dentist  the 
most  important  in  the  skeleton,  on  account  of  the  many  dis- 
eases to  which  it  is  liable.  Next  to  the  mandible,  it  is  the 
largest  bone  of  this  region,  and  forms,  by  union  with  its 
fellow  of  the  opposite  side,  the  upper  jaw.  The  two  bones 
assist  in  the  formation  of  three  cavities,  forming  the  roof 
of  the  oral  cavity,  the  floor  of  the  orbital  cavity,  and  the 
external  walls  of  the  nasal  cavities.  They  also  enter  into 
the  formation  of  the  zygomatic  and  sphenopalatine  fossa, 
and  the  sphenomaxillary  and  pterygomaxillary  fissures. 

334 


ANATOMY 


335 


The  cavity  of  the  maxilla  is  the  antrum  of  Highmore. 
It  is  pyramidal,  with  its  apex  outward  and  formed  by  the 
malar  process,  and  its  base  formed  by  the  lateral  wall  of 
the  nasal  cavity.    Its  superior  boundary  forms  the  floor 


Fig.  169. — A  Section 
Cut  Anteriorly  to 
THE  Second  Molar 
Teeth.  In  this  case 
the  maxillary  sinuses 
are  almost  cuboidal  in 
shape  and  extend 
down  below  the  level 
of  the  nose,  and  up- 
ward into  the  region 
of  the  middle  ethmoi- 
dal cells.  The  inner 
walls  are  not  straight, 
as  they  are  in  a 
typical  skuU.  Begin- 
ning at  the  floor  of  the 
antrum,  almost  over 
the  center  of  the  dome 
of  the  mouth,  the 
inner  wall  extends  up- 
ward in  a  convex  man- 
ner to  the  point  at 
which  the  inferior  tur- 
binal  projects  into  the 
nasal  cavity.  There  is 
a  direct  communica- 
tion with  the  anterior 
ethmoidal  cells  and  the 
frontal    sinuses. 

(After  Cryor.) 

of  the  orbit,  while  its  floor  is  formed  by  the  alveolar  process. 
Its  anterior  wall  constitutes  the  face,  while  its  posterior 
wall  goes  to  form  the  zygomatic  surface.  Through  its  base, 
or  inner  wall,  passes  the  only  foramen  of  exit,  leading  into 
the  nasal  cavity,  high  up  and  well  back,  and  terminating 


Fig.  167. — A  Section 
Cut  Vertically  in 
the  Region  of  the 
Second  Molar 
Tooth.  The  frontal 
sinuses  wiU  be  ob- 
served passing  well 
over  the  orbits,  and 
the  cell  in  the  crista 
galli  is  clearly  shown. 
The  inner  surfaces  of 
the  anterior  walls  of 
the  bulla  ethmoidalis 
will  be  observed  ex- 
tending inward  to- 
ward the  middle  tur- 
binate bones,  the  wire 
marking  the  infundi- 
bulum,  the  hiatus 
semilunaris,  and  the 
osteum  maxillary 
sinus,  the  last  named 
being  small  in  pro- 
portion to  the  size 
of  the  skull. 


Fig.  168.— a  Trans- 
verse Vertical  Sec- 
tion. The  anterior 
cut  is  made  in  the  re- 
gion of  the  premolar 
teeth.  It  will  be  no- 
ticed that  the  septum 
of  the  nose  is  deflected 
and  the  spur  comes  in 
contact  with  the  right 
turbinal.  The  frontal 
sinuses  are  large,  ex- 
tending outward  over 
the  orbits.  They  also 
extend  down  below 
the  middle  of  the 
orbit.  Between  the 
two  frontal  sinuses 
there  is  an  inter- 
frontal  cell  extending 
backward  into  the 
crista  galli,  which  is 
shown  in  Fig.  167.  It 
will  be  noticed  that  a 
wire  passes  from  the 
right  frontal  sinus 
downward  and  is  again 
seen  in  the  antrum. 


336 


DISEASES    OF    THE    SINUSES 


in  the  middle  meatus  or  under  the  middle  turbinated  bone. 
In  the  green  state  of  the  skull  usually  but  one  orifice  ex- 
ists, but  in  the  prepared  skull  two  are  found,  one  of  which 
is  closed  by  the  mucous  membrane  during  life.  Projecting 
lamina  of  bone  are  frequently  found  crossing  the  cavity, 
most  frequently  on  the  floor,  separating  the  cavity  into  sev- 
eral compartments  and  making  a  most  troublesome  compli- 
cation in  diseased  conditions. 

There  are  also  found  projecting  from  the  floor  several 


Fig.  170. — Antero-posterior  Section  Through  the  Antrum  near  the 
Nasoantral  Septum.  Showing  an  unusually  large  antral  cavity  extend- 
ing well  forward  and  upward. 

conical  processes  corresponding  to  the  roots  of  the  first  and 
second  molar  teeth,  which  in  some  cases  perforate  the  floor. 
Through  the  posterior  wall  pass  the  posterior  dental  canals 
for  the  transmission  of  the  posterior  dental  nerves,  a 
branch  of  the  second  division  of  the  fifth  nerve  and  a  branch 
of  the  internal  maxillary  artery  of  the  same  name  as, the 
nerve. 

Owing  to  the  extreme  thinness  of  the  walls,  which  in 
places  may  even  be  absent,  tumors  or  accumulations  force 
out  in  every  direction,  encroaching  upon  adjacent  parts, 
displacing  the  eyeball,  occluding  the  nasal  cavity,  bulging 


ANATOMY  337 

the  cheek,  and  forcing  down  the  alveolus  and  making  pres- 
sure backward  into  the  zygomatic  fossa. 

The  maxillary  cavity  is  situated  immediately  above  the 
alveolar  process.     The  base  or  internal  wall,  constituting 


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Fig.  171. — Transverse  Section  Just  Anterior  to  the  Ostium  Maxillare. 
F,  frontal  sinuses,  with  arrows  passing  through  their  ostia  directly  into  the 
middle  meatus  without  entering  the  infundibulum  (i);  a,  a,  anterior  ethmoid 
cells;  A,  antrum.  Arrows  pass  into  the  infundibulum  (i)  through  the  ostium 
maxillare,  thence  through  the  hiatus  semilunaris  into  the  middle  meatus 
under  the  middle  turbinate  bone.  U,  uncinate  process,  which  is  placed 
obliquely  and  forms  the  internal  wall  of  the  infundibulum;  s,  septum  nasi; 
m.t.,  middle  turbinate.  On  the  left  side  this  turbinate  contains  a  cell  (c) 
which  communicates  with  the  middle  meatus,  as  shown  by  an  arrow.  i.L, 
inferior  turbinate;  o.p.,  os  planum.     (Lathrop.) 

the  external  wall  of  the  nasal  cavity,  is  immediately  above 
and  on  a  perpendicular  line  with  the  internal  surface  of  the 
alveolar  process  from  the  second  bicuspid  backward  to  the 
last  molar.  A  drill  passed  perpendicularly  up  through  the 
roof  of  the  mouth  will  enter  the  nasal  cavity  and  not  the 


338  DISEASES    OF    THE    SINUSES 

antrum.  The  apex  of  the  antrum  (as  it  is  formed  by  the 
malar  process  of  the  maxilla)  projects  outward  beyond  the 
external  alveolar  line  about  one-half  the  length  of  the  cavity. 
It  begins  at  the  canine  fossa,  or  about  perpendicular  to  the 
first  bicuspid.  The  author  saw  a  case  where  antral  disease 
was  suspected,  because  of  a  discharging  sinus  which  termi- 


FiG.  172. — Lateral  Wall  of  Antrum.  This  figure  is  introduced  to  show  that 
the  antral  cavity  does  not  extend  internal  to  the  internal  surface  of  the 
alveolar  process  above  the  molar  teeth.  The  following  law  may  be  appended, 
viz.:  A  line  bisecting  the  nasoantral  partition  will  pass  along  the  internal  sur- 
face of  the  alveolar  process  at  the  second  molar.  The  point  is  that  if  a  drill 
were  passed  through  the  roof  of  the  mouth  it  would  enter  the  nasal  cavity. 
Or,  to  enter  the  antrum,  the  drill  when  passed  through  the  socket  of  a  tooth 
must  be  directed  outward. 

nated  above  the  first  bicuspid.  Two  operations  were  per- 
formed by  a  surgeon  for  antral  disease,  but  a  canine  tooth 
was  found  up  in  the  walls  of  the  maxilla,  anterior  to  the 
antrum,  and  removed.  The  antrum  was  not  entered  at 
either  operation.  It  must  be  remembered  that  the  antrum 
does  not  extend  as  far  forward  as  the  canine  fossa. 

Drainage. — The  antral  cavity  has  no  normal  drainage 
except  through  its  orifice  terminating  in  the  middle  meatus 


DISEASES  OF  THE  ANTRUM  339 

of  the  nose.  This  opening  ends  in  the  hiatus  semilunaris, 
which  is  in  close  proximity  to  the  infundibulum,  the  open- 
ing from  the  frontal  sinus,  and  drainage  from  the  latter 
may  readily  pass  into  the  antrum.  Fluid  has  ready  escape 
through  the  antral  opening,  but  the  nasal  secretion  does 
not  enter  this  cavity  because  the  unciform  process  in  front 
of  the  opening  acts  as  a  guard,  and  fluid  is  deflected  along 
the  hiatus  semilunaris.  The  antral  or  frontal  mucous  mem- 
brane normally  secretes  only  enough  mucus  to  keep  these 
membranes  moist  and  properly  lubricated. 


DISEASES  OF  THE  ANTRUM 

Owing  to  the  immediate  proximity  of  this  cavity  to  the 
field  of  dental  operation,  the  surgery  of  the  antrum  con- 
cerns the  dentist  most.  Certain  pathological  conditions  of 
the  mouth  are  so  intimately  associated  with  diseases  of  the 
antrum  that  a  differential  diagnosis  is  most  difficult.  Pain, 
swelling  and  face-ache  are  all  characteristic  of  inflammatory 
changes  about  a  tooth  as  well  as  of  antral  diseases.  So, 
also,  do  suppurative  changes  about  the  alveolar  process  re- 
semble antral  suppuration,  and  it  is  difficult  to  determine 
which  might  have  been  the  primary  trouble.  A  thorough 
knowledge  of  the  anatomy  of  the  maxilla  and  of  the  general 
pathological  changes  occurring  in  this  bone  and  in  the  soft 
structures  about  it  is  necessary  if  the  dentist  is  to  differen- 
tiate a  true  tooth  change  from  one  of  a  more  severe  charac- 
ter. Many  teeth  are  sacrificed  in  making  a  diagnosis,  when, 
with  an  intimate  knowledge  of  every  diseased  condition 
about  the  mouth,  they  might  have  been  preserved  and  a 
more  prompt  recovery  might  have  been  insured. 

It  must  not  be  concluded  that,  because  the  antrum  has 
a  fistulous  opening  leading  into  the  oral  cavity,  it  is  "dis- 
eased," for  such  an  opening  may  exist  without  infection 
or  suppuration. 


340  DISEASES    OF    THE    SINUSES 

Classification.— From  an  etiological  standpoint  the  fol- 
lowing would  appear  to  be  the  best  classification : 

(1)  Diseases  and  injuries  from  teeth. 

(a)  Tooth  extractions  wdth  a  rupture  into  the  an- 

trum (through  the  floor). 

(b)  Carious  teeth  and  alveolar  abscess  with  an 

extension  of  the  disease  to  the  maxillary 
floor,  finally  destroying  the  muco-periosteal 
lining  of  the  cavity. 

(2)  Traumatism. 

(3)  Acute  infections. 

(a)  Inflammatory   diseases    of   the   nasal   cavity, 

such  as  acute  coryza,  catarrh,  and  grip. 

(b)  The   acute   exanthematous   and  other  fevers, 

such  as  scarlatina,  measles,  typhoid  and 
pneumonia. 

(4)  Neoplasms. 

(a)  Polypoid  growths  and  mucous  engorgement. 

(b)  Mucous  cysts,  or  polypi,  associated  with  nasal 

growths  of  the  same  sort. 

(c)  Other  tumors  and  growths  within  the  cavity 

or  in  its  walls. 

(5)  Destructive  diseases  of  the  bones. 

(a)  Osteomyelitis. 

(b)  Periostitis. 

(c)  Tuberculous  disease. 

(d)  Syphilis. 

(1)  Diseases  and  Injuries  from  Teeth.— (a)  Extrac- 
tions.— Probably  twenty-five  per  cent,  of  all  cases  of  antral 
diseases  are  caused  by  tooth  extractions.  In  an  examina- 
tion of  many  skulls  it  was  found  that  the  second  roots  of 
the  second  bicuspid  and  of  the  first  and  second  molars  not 
infrequently  extended  quite  up  to  and  sometimes  through 
the  floor  of  the  antrum,  leaving,  after  extraction,  the  soft 
structures  only  as  a  membranous  protection.    It  must  be 


DISEASES   OP   THE   ANTRUM  341 

remembered  that  the  roots  of  teeth  are  somewhat  irregular 
in  position,  and  they  may  be  found  at  every  angle,  and 
curved  in  many  varied  directions.  Not  infrequently  two 
roots  of  the  molar  project  into  the  compact  structures  of 
the  floor,  and,  if  extraction  was  done  for  pain  from  acute 
inflammation  about  the  roots,  other  inflammations  may  have 
preceded,  resulting  in  destruction  of  the  peridental  mem- 
brane and  ossification  between  them.  In  such  a  condition  a 
portion  of  bone  is  usually  carried  along  with  the  tooth,  for 
the  ossification  is  usually  more  firm  than  the  thin  plate  of 
the  bone  constituting  the  floor  of  the  antrum.  Again,  dur- 
ing the  extraction  of  a  root,  the  act  of  going  down  between 
the  alveolar  ridges  for  the  root,  may,  instead  of  bringing 
it  within  the  grasp  of  the  instrument,  push  it  in  front  and 
into  the  antral  cavity. 

It  may  also  be  stated  that  teeth  sometimes  grow  upward 
instead  of  downward,  and  erupt  into  the  antrum  instead  of 
through  the  alveolus.  Marshall  reports  a  case  of  this  kind, 
with  a  history  of  suffering  extending  over  a  period  of  six- 
teen years,  in  which  a  tooth  was  dropped  from  the  nose 
while  the  head  was  thrown  forward. 

(b)  Carious  teeth  or  alveolar  abscess  or  devitalized 
pulp,  or  infection  extending  from  periostitis,  may  by  metas- 
tasis involve  the  periosteal  lining  of  the  antrum,  finally 
infecting  the  mucous  membrane  of  the  cavity  and  producing 
a  suppurative  antritis.  Marshall  thinks  that  alveolar  ab- 
scess is  the  most  common  factor  in  producing  suppurative 
conditions  of  the  antrum.  There  is  a  difference  of  opinion 
as  to  whether  antral  disease  reaches  the  root  of  a  tooth  and 
produces,  secondarily,  an  alveolar  abscess,  or  whether  cari- 
ous teeth  and  primary  abscess  produce  antral  suppuration. 
Mears  and  several  other  authorities  are  of  the  latter 
opinion,  while  Dawburn,  Stout  and  others  oppose  this  posi- 
tion. 

(2)  Traumatisms.— Here  may  be  enumerated  traumatic 
causes  other  than  those  resultinor  from  tooth  extractions, 


342  DISEASES    OF    THE    SINUSES 

such  as  fracture  into  the  cavity  ^vith  involvement  of  the 
mucous  membrane,  punctures  of  the  face  by  wood,  or  in- 
juries due  to  missiles  during  fights  or  accidents.  These 
are  not  frequent  causes  of  disease  of  this  cavity.  Other  for- 
eign bodies,  as  bullets,  etc.,  when  they  find  lodgment  in  the 
antrum,  cause  suppurative  disease  of  this  cavity.  In  old 
sinuses  following  antral  diseases,  which  are  otherwise  well, 
particles  of  food  may  gain  access  and  thus  set  up  a  suppura- 
tive antritis,  requiring  the  removal  of  the  foreign  substance 
before  acute  symptoms  subside. 

(3)  Acute  Infections.— (a)  Inflammatory  diseases  of 
the  mucous  membrane  of  the  nasal  cavity  may  extend  into 
the  antrum,  resulting  in  suppuration.  Catarrhal  affections, 
when  atrophic,  usually  involve  the  antrum.  This  occurs 
quite  commonly.  Grip  in  many  instances  leaves  suppura- 
tive diseases  of  the  antrum  as  sequelae.  Repeated  colds, 
the  most  manifest  symptom  of  which  is  coryza,  so  common 
during  the  winter  in  damp  climates,  are  a  cause  of  antral 
supi^uration  by  the  extension  of  the  germs  from  the  nasal 
to  the  antral  mucous  membrane. 

Acute  frontal  infection  occurs  quite  frequently,  but, 
owing  to  the  perfect  drainage  which  the  course  of  the  in- 
fundibulum  furnishes  to  the  frontal  sinuses,  chronic  disease 
is  quite  rare.  In  considering  antral  suppuration  due  to,  or 
associated  with,  nasal  inflammation,  the  condition  of  the 
turbinate  bones  must  be  studied.  In  hypertrophic  rhinitis 
the  mucous  membrane  is  so  engorged  and  thickened  that  the 
nasal  cavity  is  obstructed,  which  condition  necessarily 
closes  the  antro-nasal  orifice,  and  suppuration  of  the  cavity 
may  result. 

(b)  The  acute  exanthematous  diseases,  such  as  measles 
and  scarlatina,  are  productive  of  antral  disease.  Facial 
erysipelas  may  extend  to  the  nasal  and  antral  mucous  mem- 
brane, the  streptococcic  infection  of  the  cavity  does  not 
readily  subside,  and  a  chronic  suppurative  disease  is  the 
result.     Diphtheritic  membrane  not  infrequently  extends 


DISEASES    OF    THE    ANTRUM  343 

from  the  pharynx  through  the  posterior  nares  and  into  the 
antrum.  The  Klebs-LoefiQer  bacillus  in  its  development  of 
uew  membrane  destroys  the  vitality  of  the  tissues.  To 
this  is  added  the  presence  within  the  antrum  of  the  cast-off 
membrane  which  will  naturally  be  retained,  and  the  con- 
stant exposure  of  all  tissues  to  streptococcic  infection  ac- 
counts for  antral  suppuration  as  a  sequela  of  this  disease. 

(4)  Neoplasms.— Under  this  head  may  be  included  all 
growths  from  the  antral  mucous  membrane  or  bony  wall. 

(a)  Polypus  is  the  most  common  variety  of  neoplasm. 
Peavler,  of  Bristol,  Tenn.,  states  that  sixty-three  per  cent, 
of  all  cases  of  chronic  diseases  of  the  antrum  of  more  than 
one  year's  standing  are  caused  by,  or  have  present,  mucous 
polypi,  but  statistics  from  other  sources  do  not  substantiate 
this  claim.  Locelie,  a  Swiss  specialist,  gives  the  per  cent, 
at  thirty-five.  It  is  a  question  whether  nasal  polypi  cause 
antral  disease  or  whether,  as  claimed  by  one  writer,  sup- 
puration of  the  antrum  does  not  cause  the  growth  of  the 
polyi^i.  Certain  it  is  that  polypoid  growths  from  the  nasal 
mucous  membrane  so  occlude  the  cavity  as  to  obstruct  the 
escape  of  the  normal  antral  secretions,  and  the  retained 
fluid  eventually  becomes  suppurative  by  the  entrance  of 
pyogenic  bacteria. 

(b)  Mucous  cysts  of  the  antrum  develop  gradually  in 
every  direction,  resembling  in  this  respect  polypoid 
growths,  but  the  absence  of  the  latter  in  the  nasal  cavity 
does  much  to  exclude  them  in  diagnosis. 

(c)  Other  groivths  found  in  the  antrum  are  fibrous 
sarcoma,  usually  involving  the  bone  as  an  osteosarcoma, 
and,  in  the  aged,  epithelioma. 

Osteomic  tumefaction  also  develops  gradually  in  all  di- 
rections. The  author  saw  one  case  in  which  the  entire  max- 
illa became  solid  bone,  the  antrum  being  entirely  obliterated. 
Sarcoma  is  associated  ^viih  pain  and  develops  rapidly  in 
the  course  of  two  or  three  months,  and  there  is  usually 
some  temperature.     In  empyema  of  the  antrum  there  is 


344  DISEASES    OF    THE    SINUSES 

chill,  fever,  pain,  emaciation  and  general  impairment  of  the 
vital  forces. 

Symptoms  of  Suppurative  Antral  "DiseaiSef Empyema  of 
the  Antrum).- — The  symptoms  of  suppurative  antral  disease 
are  as  follows:  1st.  Pain,  which  may  be  constant,  but  is 
usually  paroxysmal.  However,  w^hen  drainage  is  good,  it 
may  be  absent.  It  is  characterized  by  an  ache  and  is  in- 
creased by  colds  and  exposure  to  a  damp,  humid  atmos- 
phere, but  is  relieved  by  local  heat.  The  pain  is  much  like 
an  ordinary  neuralgia.  It  may  be  mistaken  for  toothache, 
and  extractions  are  not  infrequently  made  with  this  idea 
in  mind.  When  antral  disease  is  due  to  extension  of  in- 
flammation from  a  suppuration  about  the  root  of  a  tooth, 
it  is  necessarily  preceded  by  the  ordinary  symptoms  of 
toothache,  with  acute  swelling  of  the  face.  2d.  Tender- 
ness, on  pressure,  of  the  entire  maxilla,  usually  found  ex- 
tending to  the  teeth,  elicited  especially  by  percussion  of  the 
latter.  3d.  Sivelling,  when  the  jDeriosteum  on  the  outside 
of  the  bone  is  involved.  4th.  Discoloration  with  swelling. 
5th.  Purulent  discharge  from  one  side  of  the  nose  when  the 
head  is  thrown  forward  with  the  suspected  side  upward, 
which  discharge  usually  greatly  reduces  the  intensity  of 
the  symptoms.  It  may  be  that  the  antronasal  foramen  is 
occluded,  preventing  the  escape  of  the  pus,  in  which  case 
the  liquid  accumulates  and  makes  pressure  upon  the  walls, 
forcing  them  out  in  every  direction,  intensifying  the  symp- 
toms of  pain  and  discomfort.  If  a  diagTiosis  is  not  made 
and  an  operation  is  not  performed  for  relief  of  the  reten- 
tion, it  usually  spontaneously  erupts  either  into  the  nasal  or 
the  oral  cavity.  During  sleep  the  pus  is  unconsciously  swal- 
lowed, producing  a  most  disagreeable  morning  nausea  and 
vomiting,  if  much  has  entered  the  stomach.  Great  disten- 
sion closes  the  nasal  cavity  by  forcing  in  the  wall,  and  the 
floor  of  the  orbit  may  be-  forced  upward  so  as  to  displace 
the  eyeball  and  disconcert  the  normal  lines  of  vision  of  the 
two  eyes.    Tumefaction  of  the  entire  side  of  the  face  is  pro- 


DISEASES   OF    THE   ANTRUM  345 

duced.  The  discharge  is  usually  very  offensive  and  is  due 
to  the  generation  of  hydrogen  sulfid  gas.  The  patient  is 
sensible  of  a  foul  taste  and  smell.  Constitutional  symptoms 
are  rigors,  which  may  become  chills,  indicating  pus  ac- 
cumulation and  retention.  These  are  followed  by  fever, 
loss  of  appetite,  and  general  lowering  of  vitality. 


Fig.  173. — X-Ray  Showing  Disease  of  Antrum  on  Right  Side  with  Pus. 
(Dr.  Geo.  C.  Johnston.) 

Diagnosis.— The  diagnosis  of  antral  disease  is  based 
upon  the  following:  1,  pain  or  face  ache;  2,  morning 
sickness;  3,  unilateral  discharge  of  pus  from  the  nose,  ac- 
celerated by  position ;  4,  tenderness  on  percussion ;  5,  fetid 
breath ;  6,  slight  swelling,  not  always  present,  except  in  re- 
tention; 7,  exploratory  operation,  when  no  pus  escapes, 
either   through  the  nasoantral   walls   or   through   a   root 


346  DISEASES    OF    THE    SINUSES 

socket,  if  one  exists,  or  preferably  tlirougli  the  outer  wall 
of  the  antrum,  of  value  in  determining  whether  the  cavity 
is  normal ;  8,  transiUumination  of  the  maxilla,  which  is  rec- 
ommended. The  eyelids  should  be  closed  to  obtain  the  best 
results.    It  shows  whether  the  antrum  is  empty  or  whether 


Fig.  174. — ^X-Rat  Showing  Disease  of  the  A:.tj   j,     :. i-  1  kontal  Sinuses  on 
THE  Left  Side,  with  Pus.     (Dr.  Geo.  C.  Johnston.) 

it  contains  some  foreign  content,  but  does  not  show  whether 
it  is  pus,  sarcoma,  polypi  or  a  cyst.     . 

Wlien  tumors  are  present  the  history  will  be  different. 
Growths  develop  usually  very  gradually,  and  the  enlarge- 
ment uniformly  encroaches  upon  all  structures.  When 
polyiioid  disease  is  present  there  are  usually  also  found 
similar  growths  in  the  nasal  cavity.  Cystic  tumors  develop 
without  symptoms  other  than  tumefaction,  and  possibly  a 
sense  of  fullness.    In  destructive  diseases  of  the  bone  result- 


DISEASES   OF   THE   ANTRUM 


347 


ing  in  secondary  involvement  of  the  antrum  the  history  is 
a  guide. 

Differential  diagnosis  must  be  made  from  tic  doulou- 
reux, in  which  the  only  symptom  is  pain ;  from  exostosis,  in 
which  the  principal  symptom  is  the  uniform  enlargement; 
from  malignant  neoplasms,  such  as  sarcoma,  angioma,  etc., 
which  have  few  if  any  constitutional  symptoms  and  no  local 
symptoms,  but  tumefaction  with  a  uniform  development. 


Fig.  175. — Mouth  after  Antral  Operation.  In  this  case  the  entire  floor  of 
antrum  was  removed.  Photograph  was  taken  several  months  after  opera- 
tion, when  architectural  arrangement  of  the  bone  was  so  changed  as  to  al- 
most obliterate  the  cavity,  being  practically  part  of  the  mouth  and  requiring 
no  packing  or  attention. 

Prognosis.— Every  case  of  antral  disease  due  to  infec- 
tion of  the  mucous  membrane  or  caused  by  non-malignant 
growths  can  be  made  comfortable,  and  the  patient  may  go 
through  life  with  comparative  ease.  It  cannot  be  prom- 
ised, however,  that,  when  suppuration  has  existed  for 
months  or  years,  the  opening  formed  to  establish  free  drain- 
age or  an  existing  fistula  can  be  closed.  In  other  words, 
all  active  symptoms  and  suppurative  conditions  can  be  con- 


348  DISEASES    OF    THE    SINUSES 

trolled,  but,  as  a  rule,  an  antro-oral  fistula  is  left — not  a 
troublesome  condition,  however,  since  modern  prosthetic 
appliances  can  so  effectually  shut  off  the  fistula  and  pre- 
vent the  entrance  of  liquids  and  food  particles  into  the  an- 
trum. 

Treatment.— The  treatment  of  diseases  of  the  antrum 
depends  greatly  upon  the  cause  of  the  trouble,  and  this 
must  be  divined  if  prompt  results  are  to  be  obtained.  The 
treatment  will  be  given  under  the  several  etiological 
heads. 

When  tooth  extractions  have  produced  an  opening  into 
the  cavity  through  a  root  socket,  resulting  in  infection  and 
suppuration,  the  first  step  in  treatment  is  to  establish  de- 
pendent drainage.  In  the  second  variety  of  cases,  depend- 
ent upon  the  extension  of  inflammation  from  carious  teeth 
or  alveolar  abscess,  as  has  already  been  intimated,  the  treat- 
ment is  drainage  by  the  extraction  of  the  offending  tooth. 
The  tooth  to  be  removed  is  not  easily  selected,  for  a  differ- 
entiation as  to  causes  is,  in  many  instances,  impossible. 
When  alveolar  abscess  exists  and  the  usual  local  remedies 
do  not  control  the  discharge,  or  if  the  discharge  appears 
to  be  from  a  definite  point,  a  thorough  exploration  should 
be  made  with  a  fine  probe.  A  free  escape  of  pus  following 
such  an  extraction  will  go  far  to  establish  the  diagnosis, 
and  a  probe  will  confirm  it.  It  is  not,  however,  an  easy  mat- 
ter to  find  the  orifice.  Continued  discharge  of  pus  should 
cause  one  to  suspect  antral  disease  or  a  destructive  dis- 
ease of  the  maxilla.  It  is  not  wise  to  perforate  the  antrum 
whenever  such  symptoms  exist,  for  periostitis  or  syphilis 
or  odontomata  may  have  a  sinus  leading  to  the  seat  of  the 
trouble  which  is  without  the  antrum.  For  cases,  see  chap- 
ter on  Tumors. 

For  the  reason  that  an  antrum,  once  open,  generally 
remains  open,  great  care  should  be  practiced  to  avoid  punc- 
ture. When  an  antrum  is  once  opened,  of  course  it  can  be 
claimed  that  there  is  antral  disease,  for  infection  and  sup- 


DISEASES  OF  THE  ANTRUM  349 

puration  usually  follow,  whether  they  existed  previous 
to  the  operation  or  not,  and  the  claim  is  verified  and  a 
diagnosis  falsely  confirmed.  When  a  diagnosis  is  made 
early,  before  destruction  of  the  wall  has  occurred,  and  when 
no  sinus  exists,  with  proper  medication  and  placing  of  the 
head  in  a  position  to  favor  drainage,  there  is  no  reason  why 
recovery  should  not  take  place  and  iDractically  a  normal 
condition  of  the  parts  result. 

Injuries  to  the  bony  wall  rarely  result  in  antral  suppura- 
tion, unless  the  injury  produces  an  antrooral  fistula.  The 
treatment  does  not  differ  from  that  for  suppuration  from 
other  causes. 

Inflammatory  diseases  of  the  nasal  cavity  which  extend 
into  the  antrum  require  treatment  for  the  correction  of  the 
nasal  trouble.  If  catarrhal,  this  should  be  treated  as  such ; 
if  there  is  a  hypertrophic  condition  of  the  turbinated  bones, 
they  should  be  amputated.  In  atrophic  rhinitis  local  im- 
provement of  the  tissues  may  be  expected  after  a  curette- 
ment  of  the  cavity,  followed  by  irrigation  by  or  inhalation 
of  a  bland  solution  of  salt  and  water  at  the  temperature 
and  specific  gravity  of  the  human  blood.  Infection  of  the 
antrum  from  acute  coryza  is  not  uncommon,  a  condition 
similar  to  infection  of  the  frontal  and  ethmoid  sinuses, 
called  a  ''cold  in  the  head,"  and  chronic  suppuration  does 
not  often  follow. 

As  the  claim  is  made  by  competent  authorities  that  from 
thirty-five  to  sixty-three  per  cent,  of  all  chronic  antral  dis- 
eases have  nasal  polypi  as  an  associated  condition,  it  is  of 
vital  importance  that  the  nasal  cavity  be  thoroughly  ex- 
plored. The  first  step  in  treatment  is  the  removal  of  the 
nasal  growths  to  ascertain  whether  true  antral  disease  ex- 
ists, or  whether  the  nasal  tumors  occlude  the  antral  orifice 
and  prevent  the  escape  of  the  normal  fluid.  Not  infre- 
quently what  appear  to  be  symptoms  of  antral  disease  dis- 
appear after  the  nasal  cavity  is  evacuated  and  nasal  breath- 
ing restored.     When  there  is  no  question  as  to  the  exist- 


350  DISEASES    OF    THE    SINUSES 

ence  of  polypi  in  the  antrum,  an  open  operation  should  be 
done. 

Mucous  cysts  of  the  antrum  require  similar  treatment. 

When  the  acute  exanthemata,  or  fevers,  have  aa  a  se- 
quela suppurative  antritis  which  does  not  yield  to  treat- 
ment through  the  nose  in  the  course  of  several  weeks,  drain- 
age should  be  established. 

Operations. — The  Oral  Route. — When  the  tooth  is  in- 
volved or  suspected,  or  when  a  tooth  of  election  is  absent, 
it  is  best  to  enter  the  antrum  through  a  tooth  socket.  When 
no  teeth  have  been  extracted,  or  when  the  teeth  are  free 
from  caries  or  other  disease,  the  following  method  of  en- 
tering the  antrum  is  the  practice  of  the  author.  The  oper- 
ation consists  in  entering  the  bone  through  the  eminence 
back  of  the  canine  fossa  just  in  front  of  the  malar  ridge, 
usually  between  the  roots  of  the  first  and  second  molars, 
but  low  down,  passing  the  drill  upward,  backward  and  in- 
ward, at  an  angle  of  from  thirty  to  forty-five  degrees,  but 
above  and  between  the  roots  of  the  teeth,  so  as  to  enter  the 
cavity  at  the  most  dependent  portion.  It  may  be  claimed 
for  this  operation,  first,  that  it  places  the  orifice  at  a  point 
where  the  cheek  rests  against  it,  and  when  food  is  masti- 
cated on  the  opposite  side  (and  antral  patients  should  learn 
to  do  this),  food  particles  seldom  enter,  and  with  care 
liquids  may  pass  through  the  mouth  without  causing  dis- 
turbance. Second,  drainage  is  as  good  as  when  through 
the  alveolus  and  better  than  when  through  the  outer  wall 
higher  up. 

Zerber  opens  and  evacuates  the  antrum  through  the 
canine  fossa,  then  resects  the  wall  of  the  antrum  between 
it  and  the  middle  meatus  of  the  nose,  working  through  the 
antrum.  This  opening  is,  in  fact,  nothing  more  than  an 
enlargement  of  the  natural  ostium  and  serves  for  perma- 
nent drainage.  The  mucosa  in  the  fossa  canina  is  then  su- 
tured. He  has  applied  this  method  on  fifteen  patients  and 
has  found  it  extremely  satisfactory  and  permanently  sue- 


DISEASES  OF  THE  ANTRUM  351 

cessful  for  the  most  severe  cases,  especially  those  in  which 
the  antrum  is  full  of  recesses  or  the  mucosa  is  much  degen- 
erated. The  method  combines  the  advantages  of  both  the 
Decault-Kuster  and  the  Siebenmann  methods  with  exten- 
sive natural  drainage. 

The  Nasal  Route. — L.  Rethi,  of  Vienna,  says:  ''The 
technic  of  my  operation  is  as  follows:  First  of  all,  it  is 
necessary  to  paint  with  a  cocain-adrenalin  solution  the 
lower  concha  inside  and  outside  and  the  external  nasal  wall 
of  the  lower  and  middle  nasal  duct.  As  only  a  small  quan- 
tity of  cocain  is  being  used,  there  is  no  danger  of  intoxica- 
tion. The  operation  is  nearly  entirely  painless,  and  it  is 
very  seldom  necessary  to  again  use  the  cocain  during  the 
operation.  The  lower  concha  is  then  loosened  from  its  in- 
sertion in  its  outer  two-thirds  with  one  or  two  clippings 
of  the  scissors  and  dissected  in  its  inner  one-third  with  a 
conchotome  or  curved  scissors.  The  external  wall  is  opened 
with  a  chisel  through  pressure  of  the  hand,  and  the  edges 
of  the  opening  so  formed  are  to  be  made  even  on  all  sides, 
not  only  upward  but  also  downward,  that  is,  toward  the 
external  wall  of  the  lower  as  well  as  of  the  middle  nasal 
duct,  so  that  a  broad  opening  for  communication  is  formed 
between  the  maxillary  antrum  and  the  nose." 

The  practice  of  using  canula  and  tubes  is  a  relic  of  by- 
gone days,  and  it  is  hardly  conceivable  that  they  could  be 
used  with  advantage  in  the  light  of  modern  methods  of 
practice.  They  act  as  an  irritant  and  certainly  obstruct 
the  free  exit  of  pus  if  they  extend  into  the  cavity,  and,  if 
they  do  not  so  extend,  the  pus  is  as  liable  to  run  back  of  as 
through  the  oritice  of  the  tube.  It  may  be  claimed  that  they 
prevent  closure  of  the  fistula,  but  this  is  not  necessary,  for 
there  is  little  tendency  to  close  as  long  as  pus  formation 
continues,  and  when  it  ceases,  if  it  closes  of  its  own  accord, 
well  and  good.  Such  a  condition  is  quite  desirable  unless 
active  symptoms  follow. 

Tumors  of  the  antrum  or  maxilla  do  not  differ  from 


352  DISEASES    OF    THE    SINUSES 

growths  from  other  structures  about  the  face,  and  will  not 
be  considered  under  the  head  of  antral  disease. 

(5)  Destructive  Bone  Diseases.— Periostitis,  osteomye- 
litis and  tuberculosis  as  causes  of  disease  of  the  antrum 
a  primari  are  rare,  and  when  the  antrum  becomes  so  in- 
volved it  is  secondary  to  disease  beginning  in  the  bone  and 
will  be  considered  under  the  head  of  Bone  Diseases. 

Syi^hilitic  disease  of  the  antrum  is  characterized  by  de- 
structive processes  similar  to  those  found  elsewhere,  and 
will  receive  no  discussion  here. 


CHAPTEE    XXXI 


FACIAL   yETTRATjGIA 


Xeuralgia  is  a  fnnctional  distnrbaiice  of  a  nerve,  charac- 
terized by  pain  along  its  conrse,  withont  local  symptoms, 
except  possibly  a  slight  flnsb,  and  with,  no  constitntional 
symptoms  other  than  those  which  may  be  considered  caus- 
ative factors.  The  snbject  matter  contained  in  this  chapter 
applies  especially  to  the  fifth  nerve. 

Xenralgia  is  a  disease  of  middle  and  advanced  life.  It 
occnrs  in  the  sexes  abont  equally.  Many  things  are  consid- 
ered as  causes.  It  most  frequently  develops  in  debilitated- 
anemic,  or  nenrasthenic  persons,  and  is  associated  with  con- 
stitntional diseases,  such  as  syphilis,  rheumatism,  malaria, 
gout.  etc.  It  is  difficult  in  all  cases  to  find  an  exciting  cause. 
Xeuralgia  is  no  doubt  most  frequently  due  to  some  irrita- 
tion about  the  teeth.  Impaction  of  teeth  and  the  roots  of 
teeth,  and  injuries,  such  as  fractures  and  contusions,  may 
all  be  followed  by  neuralgia.  Caries,  suppuratiom  exposed 
pulp  or  denuded  periosteum  commtmicating  with  a  very 
harmless-appearing  siaus.  latent  necrosis,  badly  adjusted 
crowns,  filling  of  teeth  without  regard  to  the  proper  prepar- 
ation of  cavities  or  with  failure  to  make  the  proper  pres- 
sure at  all  points  are  causes.  Use  of  arsenic  and  other 
drugs  in  cavities  may  also  be  causes.  The  author  once  saw 
a  case  of  neuralgia  caused  by  a  few  drops  of  tirine  being 
splashed  against  the  conjunctiva,  which  was  followed  by 
conjunctivitis  and  cellulitis  of  the  side  of  the  face  and  fore- 
head. The  pain  had  been  almost  constant  for  six  years, 
coming  and  going  in  varying  degrees  of  severity.  Damp 
climates  and  humiditv  exasrsrerate  neuralsria. 


354  FACIAL    NEURALGIA 

How  a  small  irritation  may  give  rise  to  the  most  pain- 
ful and  most  widely  distributed  of  reflex  neuroses  is  well 
illustrated  by  a  case  from  tlie  practice  of  a  dentist,  Herr- 
man  of  Halle.  He  says :  "A  man  of  forty-seven  had  suf- 
fered for  twenty  years  with  an  intense  pain,  which  began 
in  the  frontal  region,  but  afterward  involved  the  whole  right 
side  of  the  face  and  neck,  and  ultimately  resulted  in  peri- 
odical mental  excitement  accompanied  by  delusions.  A 
score  of  doctors  and  most  varied  remedial  measures  had 
been  ineffectual  in  affording  relief.  Finally  he  sought  ad- 
mission to  an  asylum,  where  the  physicians  hit  upon  a  mis- 
placed wisdom  tooth  as  the  morbid  manifestion  and  called 
in  a  dentist  to  extract  it.  In  addition  to  malposition,  its 
root  had  large  exostoses,  as  was  seen  on  removal  under 
chloroform.  A  year  has  now  elapsed  since  the  operation, 
and  the  patient  has  been  free  during  this  period  of  all 
psychical  or  neurotic  disturbance. ' ' 

A  case  of  persistent  facial  neuralgia  due  to  an  unerupted 
cuspid  tooth  is  described  by  Kirk.  (See  chapter  on  Reflex 
Neuroses.) 

Symptoms.— Pain  is  not  constant  as  a  rule,  but  there 
are  intermissions  for  a  day  or  more — possibly  a  week — be- 
tween attacks,  but  in  some  cases  it  is  practically  continuous. 
It  is  most  severe,  and  the  muscles  on  the  affected  side  of 
the  face  twitch  during  paroxysms.  It  is  the  practice  of 
patients  to  throw  their  hands  up  and  press  the  palms  firmly 
against  the  skin  to  quiet  the  muscles,  with  the  idea  of  af- 
fording relief.  The  twitching  will  be  confined  to  muscles 
supplied  by  the  division  of  the  nerve  affected.  Tender 
points  are  found  along  the  nerve  trunks  at  points  where 
they  pass  over  bony  prominences.  If  the  first  division  of 
the  fifth  nerve  is  affected,  one  point  will  be  at  the  supra- 
orbital notch.  If  the  second  division,  pressure  over  the 
infraorbital  foramen  will  cause  pain;  and  in  the  third  di- 
vision the  nerve  is  most  superficial  at  the  mental  foramen, 
and  pressure  here  usually  causes  pain.    Tenderness  may  be 


DIAGNOSIS  355 

found  over  the  entire  involved  area,  the  lii3S  or  tongue  be- 
ing so  sensitive  at  times  as  to  cause  the  patients  to  avoid 
eating  when  suffering  from  an  attack.  It  is  usual  for  the 
skin  over  the  area  of  distribution  of  the  affected  nerve  to 
be  flushed  during  a  paroxysm.  Vasomotor  or  trophic 
changes  are  not  present,  since  these  functions  are  controlled 
by  the  sympathetic  system.  Faculties  of  heat  and  cold 
sensation,  etc.,  are  impaired.  A  cold  sensation  over  the 
cheek,  forehead  or  chin  is  experienced  by  one  j)atient,  while 
the  opposite  may  be  the  experience  of  another.  In  neural- 
gia per  se  there  is  no  temperature  or  constitutional  disturb- 
ance, and  when  these  are  present  the  cause  of  the  pain  is 
inflammatory  changes.  Arterial  sclerosis  is  often  found 
as  an  associated  condition,  but  whether  it  is  the  cause  or  the 
result  has  not  been  determined.  The  exact  location  of  the 
cause  in  many  cases  is  difficult  to  determine.  Some  patients 
are  entirely  relieved  by  peripheral  operations,  others  re- 
quire central  resections,  and  even  then  the  relief  is  in  some 
cases  only  temporary. 

The  right  fifth  nerve  is  affected  twice  as  often  as  the 
left.  In  fifty-three  cases  reported  by  Tiffany,  ten  were  of 
the  third  division,  six  of  the  second,  twenty-two  of  all  di- 
visions, and  the  remaining  fourteen  of  the  second  and 
third  combined.    In  no  case  was  the  first  affected  alone. 

Diagnosis. — Diagnosis  must  be  made  from  all  inflamma- 
tory diseases  of  the  bones  and  structures  of  the  face.  Osteo- 
myelitis, periostitis,  syphilis,  antral  diseases,  diseases  of 
the  teeth,  and  ulcerative  and  cancerous  diseases  of  the  soft 
structures  must  all  be  taken  into  account  and  excluded. 
When  there  is  persistent  pain  anywhere  within  the  area  of 
distribution  of  the  fifth  nerve,  without  a  well-defined  cause 
elsewhere,  the  teeth  should  be  thoroughly  examined,  since 
in  the  majority  of  cases  the  irritant  will  be  found  there. 
Neuritis,  which  is  an  inflammation  of  the  connective  tissue 
of  a  nerve,  is  an  acute  process,  but  may  be  followed  by  neu- 
ralgia.   Necrosis  of  the  alveolar  process,  with  removal  of 


356  FACIAL    NEURALGIA 

considerable  bone,  wliicli  is  necessarily  followed  by  the 
formation  of  extensive  cicatrices,  involves  the  nerve  ter- 
minals or  a  considerable  trunk  and  produces  severe  neural- 
gia. In  malarial  neuralgia,  in  the  form  of  ''brow  ague," 
the  pain  comes  on  at  a  particular  hour  every  day,  and,  after 
continuing  for  from  one  to  three  hours,  disappears  entirely. 
Syphilitic  pain  is  more  severe  at  night. 

Prognosis. — Andrews  presents  the  results  of  his  expe- 
rience w4th  relapsing  cases.  He  says  that  "neurectomy 
performed  for  tic  douloureux  permanently  cures  some  pa- 
tients and  effectually  stops  the  pain  of  nearly  all  of  the  rest 
for  a  period  of  from  four  to  six  months  to  nearly  two  years, 
but  the  majority  sooner  or  later  relapse. ' '  Clinical  experi- 
ence has  demonstrated  to  the  author  the  valuable  fact  that 
these  relapsing  cases  may  be  freed  from  their  pain  for  con- 
siderable intervals  of  time  by  operations  repeated  at  the 
site  of  the  original  operative  cicatrix.  According  to  An- 
drews, it  is  not  necessary  to  find  the  central  stump  of  this 
resected  nerve  and  subject  it  directly  either  to  traction  or 
excision ;  it  suffices  simply  to  remove  the  scar-  tissue  re- 
sulting from  the  previous  operation.  The  immediate  and 
prolonged  benefit  resulting  from  the  avulsion  of  the  scar- 
tissue  is  explained  by  the  stretching  to  which  the  nerve 
stump  is  subjected  in  thus  forcibly  tearing  away  the 
cicatrix. 

Treatment.— Treatment  may  be  divided  into:  1.  medical 
treatment ;  2.  injections ;  3.  operations,  which  may  be  periph- 
eral or  deep. 

1.  Medical  Treatment. — In  all  cases  of  facial  neuralgia, 
medical  treatment  should  be  thoroughly  tried  before  opera- 
tions are  performed.  The  chief  remedies  are  belladonna, 
aconite,  strychnia,  gelsemium,  and  large  doses  of  quinin. 
Locally,  heat,  electricity,  menthol  and  ether  are  used  with 
benefit.  The  coal-tar  anodynes  afford  relief  in  some  cases. 
Pain  recurring  daily,  known  as  ''brow  ague,"  due  to  ma- 
laria, is  quite  common  in  malarial  regions,  and  is  readily 


TREATMENT  357 

cured  with  arsenic.  Begin  giving  Fowler's  solution  with 
five  drops  three  times  daily,  increasing  by  one  drop  each 
day  to  fifteen,  or  even  thirty,  drop  doses.  When  pain  dis- 
appears, gradually  diminish  the  dose. 

2.  Injections. — Deep  injections  of  alcohol  as  a  method  of 
relieving  the  intense  pain  of  facial  neuralgia  were  intro- 
duced by  Levy  and  Baudouin,  of  Saltpetriere,  and  Dr.  Pat- 
rick, of  Chicago,  made  a  personal  study  of4heir  method  and 
used  it  upon  one  hundred  cases,  with  quite  flattering  results. 
He  may  be  quoted  as  follows : 

^'The  aim  is  to  reach  the  inferior  maxillary  branch  of 
the  fifth  nerve  just  after  its  exit  from  the  foramen  ovale, 
the  superior  maxillary  branch  just  after  its  exit  from  the 
foramen  rotundum,  and  the  first  or  supraorbital  branch  im- 
mediately after  its  entrance  into  the  orbit,  and  to  place  an 
injection  of  alcohol  at  these  points,  within  the  nerve  sheath 
if  possible.  The  instrument  employed  is  a  straight  needle, 
1.5  mm.  in  diameter  and  10  cm.  long,  fitted  with  a  stylet 
exactly  like  a  trocar,  except  that  in  this  case  the  needle  is 
sharp  and  the  stylet  blunt.  The  needle  is  marked  in  centi- 
meters from  the  point  up  to  five,  so  that  the  operator  may 
know  what  depth  he  has  reached.  In  making  the  operation 
the  stylet  is  at  first  slightly  withdrawn,  and  the  puncture 
is  made  with  the  sharp  point  of  the  needle.  After  the  point 
is  well  through  the  skin  and  subcutaneous  tissue,  the  stylet 
is  pushed  home.  In  this  position  its  end  is  flush  with  the 
needle  point,  making  a  blunt  instrument  for  the  remainder 
of  the  penetration ;  this  avoids  injury  of  deep  blood  vessels. 
Having  obtained  the  proper  depth,  the  stylet  is  withdrawn, 
the  syringe,  already  filled,  is  fitted  to  the  needle,  and  the 
injection  is  slowly  made.  Ordinarily  the  needle  should  be 
allowed  to  remain  in  situ  a  couple  of  minutes  to  avoid  any 
oozing  from  the  puncture.  Pressure  for  a  few  minutes  has 
always  controlled  such  oozing.  Sometimes  there  is  no 
bleeding.    A  touch  of  collodion  serves  as  dressing. 

''The  solution  first  used  is  75  per  cent,  alcohol  contain- 


358 


FACIAL    NEURALGIA 


ing  chloroform  and  cocain.  The  following  should  be  used  to 
begin  with: 

Cocain  hydrochlorate gr.  i 

Chloroform m  x 

Alcohol z  iii 

Distilled  water,  enough  to  make  z  ss 
Mix. 

''Of  this  2  CO.  are  injected.  For  succeeding  injections 
the  proportion  of  alcohol  is  increased  so  that  if  several  are 
needed  for  the  same  branch,  the  strength  of  the  solution 

reaches  about  90  per  cent.  For 
reaching  the  different  branches 
of  the  nerve  the  procedure  is 
as  follows:    (Figure  176.) 

"For  the  inferior  branch 
the  needle  is  inserted  at  the 
lower  border  of  the  zygoma  2.5 
cm.  in  front  of  the  descending 
root  of  the  zygoma,  which  al- 
ways can  be  felt,  and  almost 
coincides  with  the  anterior 
bony  border  of  the  external 
auditory  meatus.  The  needle 
is  directed  slightly  upward, 
so  as  to  hug  the  base  of  the 
skull,  and  a  little  backward, 
and  at  a  depth  of  4  cm.  should 
Zfirit  *«rd  L'S'thTrf  di!    reach  the  nerve  at  its  exit  from 

the  cranium. 

"To  attain  the  middle 
branch,  the  line  of  the  posterior  border  of  the  ascending 
(orbital)  process  of  the  malar  bone  (ascending  to  articulate 
with  the  frontal)  is  prolonged  to  the  lower  border  of  the 
zygoma  and  the  needle  inserted  .5  cm.  posterior  to  this 
point.    It  is  directed  vertically  to  the  anteroposterior  line, 


Fig.  176. — Deep  Injections  for 
Neuralgia.  Showing  the  course 
the  needles  take  under  the  zygo 


visions   of  the  fifth  nerve  at  the 
foramina  rotundum  and  ovale. 


TREATMENT  359 

but  inclined  slightly  upward  in  a  direction  which  would 
attain,  at  the  depth  of  the  foramen  rotundum,  the  level  of 
the  inferior  extremity  of  the  nasal  bones.  At  a  depth 
of  5  cm.  the  nerve  is  reached  at  its  emergence  from  the 
foramen  rotundum  into  the  pterygomaxillary  fossa." 

Levy  and  Baudouin  advise  reaching  the  supraorbital 
branch  by  inserting  the  needle  at  the  external  margin  of  the 
orbit  opposite  the  frontomalar  articulation  (suture),  pass- 
ing it  along  the  external  orbital  wall  to  a  depth  of  3.5  to  4 
cm.,  when  the  point  should  reach  the  nerve.  This  injection 
Dr.  Patrick  has  made  but  once. 

Superficial  Injections. — Before  major  operations  are 
performed  it  is  advisable  to  inject  alcohol  into  the  nerves 
at  their  points  of  exit  from  the  anterior  surface  of  the  skull. 

For  the  first  division,  the  needle  should  enter  the  supra- 
orbital notch.  For  the  second  division,  the  infraorbital  for- 
amen is  selected,  the  needle  passing  well  into  the  bone.  For 
the  third  division,  the  needle  should  be  passed  into  the 
mental  foramen  in  the  same  manner. 

The  solution  to  be  used  is  that  given  above  for  deep  in- 
jections. 

3.  OPEEATioisrs. — The  question  of  operating  is  under 
debate,  and  the  time  to  operate  is  just  as  unsettled.  One 
operator  advises  an  early  operation,  while  another  recom- 
mends delay,  using  medicines  and  other  means,  hoping  that 
the  cause  will  be  removed  short  of  a  major  operation.  The 
various  procedures  recommended  below  are  those  usually 
practiced,  in  the  order  in  which  they  are  given. 

Peripheral  operations  are  divided  as  follows:  (a) 
Nerve  stretching;  (b)  avulsion;  (c)  neurotomy;  (d)  neu- 
rectomy; (e)  deep  operations. 

(a)  Nerve  stretching  consists  in  exposing  the  nerve  by 
cutting  down  to  the  sheath  at  the  most  superficial  point; 
isolating  it  by  careful  dissection,  and,  if  it  be  the  supra-  or 
infraorbital,  passing  a  blunt  hook  beneath  it,  and  making 
sufficient  traction  in  both  directions.    Vogt  says  that  a  nerve 


360  FACIAL    NEURALGIA 

can  be  stretched  one-twentieth  of  its  length.  Considerable 
tension  may  be  made,  since  the  simple  act  of  stretching  is 
of  questionable  value  if  stopped  short  of  a  rupture  of  the 
fibers. 

(b)  Avulsion  of  Thiersch  consists  in  carrying  stretch- 
ing to  the  point  of  completely  tearing  the  nerve  away,  both 
from  its  periphery  as  well  as  from  the  deeper  structures. 
For  neuralgia  of  the  ophthalmic  division,  an  incision  is 
made  over  the  superior  orbital  notch,  the  nerve  is  isolated, 
and  seized  with  a  hemostat.  By  gradually  twisting  toward 
the  periphery,  the  terminal  trunks  are  drawn  from  beneath 
the  skin  for  possibly  an  inch.  The  nerve  is  freed  from  the 
notch,  or,  if  a  foramen  exists,  chiseled  away,  care  being 
taken  to  avoid  injuring  the  nerve,  and  while  slight  traction 
is  being  made  upon  the  nerve  with  a  hemostat  it  is  dissected 
away  from  other  structures  with  a  narrow,  blunt  periosteo- 
tome  as  far  back  as  practicable.  The  nerve  is  now  wound 
about  the  forceps  until  it  gives  away.  The  traction  thus 
made  is  supposed  to  have  a  beneficial  influence  upon  the 
nerve  trunk  even  back  as  far  as  its  origin  from  the  Gas- 
serian  ganglion.  Avulsion  of  the  second  division  is  done 
much  in  the  same  way.  A  '^T"  incision  is  made  over  the 
infraorbital  foramen,  the  stem  of  the  incision  extending 
downward  through  the  cheek.  After  the  nerve  is  exposed, 
it  may  be  torn  from  its  peripheral  attachment.  It  is  now 
necessary  to  open  the  canal  by  chiseling  away  the  bone, 
making  the  opening  sufficiently  large  to  permit  the  nerve 
to  be  forced  back  along  the  floor  of  the  orbit  to  near  its 
apex.  This  is  done  with  a  narrow  periosteal  elevator.  The 
nerve  thus  freed  is  grasped  as  deeply  down  as  possible  by 
a  narrow  but  strong  forceps,  and  by  tugging  and  twisting 
may  be  torn  from  its  exit  through  the  foramen  rotundum. 
Torsion  of  the  nerve  must  be  done  very  slowly,  gradually 
winding  the  nerve  about  the  forceps.  The  same  operation 
may  be  made  for  neuralgia  of  the  mandibular  nerve,  the 
traction  being  made  as  the  nerve  makes  its  exit,  or  a  portion 


TREATMENT 


361 


of  the  nerve  may  be  exposed  by  chiseling  the  bone  away.  It 
is  thought  impossible  to  remove  the  entire  nerve  back  as  far 
as  the  last  tooth,  in  this  manner  accomplishing  as  much  as 


Fig.  177. — Method  of  Exposing  the  Supraorbital  Branch  of  the  Fifth 

Nerve. 


Fig.  178. — Exposed  Infraorbital  Branch  of  the  Fifth  Nerve  as  it  Emerges 
Through  the  Infraorbital  Foramen,  also  Where  it  Rests  in  the 
Groove  Along  the  Floor  of  the  Orbit. 

can  be  done  by  neurotomy  at  the  inferior  dental  canal. 
When  simple  avulsion  of  the  third  division  of  the  nerve,  as 
shown  in  figure  179,  does  not  give  relief,  the  bone  may  be 
chiseled  away  down  to  the  central  canal  from  the  mental 


362  FACIAL    NEUEALGIA 

foramen.  An  inch  or  more  of  the  central  canal  may  be 
opened  in  this  way  through  the  mouth.  The  nerve  is  now 
lifted  from  the  vessels  as  it  rests  in  the  canal,  and  by  grasp- 
ing it  well  back,  it  may  be  torn  away  toward  the  inferior 
dental  foramen.  Or,  if  it  is  thought  best,  a  screw  probe 
may  be  introduced  into  the  canal  and  pushed  back  as  far  as 
desired  to  the  inferior  dental  foramen  and  the  nerve  de- 
stroyed by  twisting.    In  two  cases  this  procedure  was  prac- 


FiG.  179. — Mental  Branch  at  Foramen  as  Exposed  Through  the  Mouth. 

ticed  with  success.    There  were  no  complications  during  or 
following  these  operations. 

(c)  Neurotomy,  or  nerve  section,  is  the  division  of  a 
nerve  in  its  course,  and  is  practiced  for  the  relief  of  pain 
or  spasm.  The  nerve  is  exposed,  section  is  made  with  scis- 
sors or  knife,  and  the  wound  is  closed.  Relief  usually  fol- 
lows, but  it  is  generally  temporary,  since  union  of  the  cut 
ends  takes  place  in  many  instances,  function  is  reestab- 
lished, and  pain  returns  as  a  consequence. 

(d)  Neurectomy  is  the  removal  of  a  section  of  a  nerve 
of  sufficient  length  to  guarantee  that  the  nerve  will  not  re- 
unite. Incision  through  the  skin  for  superficial  operations 
is  made  as  for  stretching  and  avulsion,  except  that  it  may 
be  longer,  in  order  that  more  of  the  nerve  may  be  exposed. 


TREATMENT  363 

Section  is  made  of  the  ophthalmic  division  as  its  branches 
emerge  from  the  skull,  as  above  described.  Nerves  may  be 
resected  at  any  point  along  their  course,  but  such  points 
have  been  selected  as  to  bring  the  nerve  trunk  as  near  the 
surface  as  possible,  or  such  routes  have  been  chosen  as 
would   offer  the  least  resistance  to  an  entrance. 

(e)  Exclusive  of  the  superficial  operations  already  de- 
scribed, each  of  the  three  branches  of  the  fifth  nerve  may 
be  reached  at  its  exit  from  the  base  of  the  skull.  The 
Gasserian  ganglion  has  frequently  been  removed  from 
within  the  cranial  cavity,  but  owing  to  the  danger  attend- 
ing this  operation,  and  because  of  the  success  of  alcohol 
injections,  it  is  not  so  frequently  resorted  to  as  it  for- 
merly was. 


CHAPTER    XXXII 


THE    SALIVAEY    GLANDS 


Congenital  absence  and  atrophy  of  the  parotid  or  other 
salivary  glands  is  a  rare  condition.  Their  absence  would 
attract  little  attention  previous  to  the  third  year,  since  their 
perfect  development  and  functional  activity  does  not  occur 
until  about  that  time.  The  absence  of  one  or  two  glands 
would  not  be  discovered,  since  a  compensatory  function 
would  be  performed  by  the  remaining  glands. 

DISEASES   OF  THE  SALIVARY  GLANDS 

The  pathological  conditions  requiring  treatment  may  be 
divided  into : 

1.  Acute  infection. 

2.  Suppuration. 

3.  Injuries  of  the  glands  or  ducts  resulting  in  fistula. 

4.  Concretions  in  the  glands  or  ducts. 

5.  Obstructions  of  the  ducts  other  than  concretions. 

6.  Malignant  growths. 

1.  Acute  Infection.— Acute  infection  of  the  salivary 
glands  is  usually  called  parotitis  or  mumps.  It  is  an  acute, 
specific,  contagious,  self-limited  infection  of  the  parotid 
gland,  attacking  principally  the  young.  Boys  are  more  lia- 
ble to  it  than  girls.  It  may  develop  at  any  age,  but  is  rarely 
seen  beyond  middle  life.  It  may  be  bilateral  or  unilateral. 
One  of  the  chief  symptoms  is  pain,  increased  by  chewing 
and  swallowing.    The  use  of  acids,  as  vinegar,  produces  an 

364 


DISEASES    OF    THE    SALIVARY   GLANDS  365 

ache  of  the  affected  parts.  Swelling  is  seen  early  and  is  lo- 
cated immediately  under  the  lobe  of  the  ear,  pushing  this  or- 
gan out  beyond  the  normal  line.  If  the  swelling  is  below  the 
ear,  leaving  a  depression  between  the  ear  and  the  tumor, 
mumps  may  be  excluded.  There  is  no  redness,  heat,  indura- 
tion or  fluctuation,  and  very  little  constitutional  disturbance. 
The  disease  develops  rapidly  and  leaves  suddenly.  It  is 
rarely  followed  by  suppuration.  Complications  are  orchitis 
in  the  male,  and  ovaritis  or  mastitis  in  the  female,  in  which 
cases  the  functional  powers  of  the  organs  affected  are  de- 
stroyed if  the  inflammation  has  been  extensive.  The  dura- 
tion is  about  ten  days  when  no  complications  develop. 
There  is  immunity  against  subsequent  attacks,  if  both 
glands  have  been  involved;  otherwise  the  remaining  gland 
may  become  infected. 

Treatment. — The  treatment  consists  in  the  use  of  salines 
to  keep  the  alimentary  canal  free  from  torpidity.  Locally, 
hot  applications  and  stimulating  aliments  are  all  that  is 
required.  In  an  adult,  recumbency  should  be  required, 
since  there  is  then  less  danger  of  metastatic  infection  of 
other  parts. 

2.  Suppuration.— Acute  enlargement  of  the  salivary 
glands,  principally  of  the  parotid,  has  been  known  to  follow 
fevers  and  septic  inflammation  of  other  parts.  Parotitis 
is  frequently  associated  with  abdominal  infections.  Hanau 
reports  five  cases  of  suppurative  inflammation  of  the  sali- 
vary glands,  two  with  appendicitis,  one  each  with  pneumo- 
nia, phthisis  and  thrush.  One  had  pyemic  parotitis  of  both 
glands.  Wlardimirow,  of  Moscow,  reports  three  cases  of 
acute  inflammation  of  the  submaxillary  glands.  The  symp- 
toms are  like  mumps,  and  in  one  of  the  cases  a  brother  of 
the  patient  had  the  mumps  at  the  same  time.  In  deep- 
seated  inflammations  of  the  glands,  running  a  rapid  course 
and  resulting  from  streptococcic  infection,  a  grave  progno- 
sis must  be  given,  since  suppuration  is  almost  always  the 
result  and  the  gland  sometimes  breaks  down  into  a  gan- 


366  THE    SALIVARY    GLANDS 

grenous  mass.  The  pus  burrows  into  the  deeper  structures, 
and  may  ojDen  into  the  ear,  blood  vessels,  air  passages,  or 
the  thoracic  cavity,  resulting  in  serious  complications. 
Other  abscesses  may  develop,  increasing  the  gravity  of  the 
trouble. 

Treatment. — The  treatment  consists  in  early  and  ef- 
fectual evacuation,  and  constant  disinfection  of  the  oral 
cavity. 

3.  Injuries  of  the  Glands  or  Ducts  Resulting  in  Fistula. 
— Injuries  of  the  ducts  of  the  salivary  glands  may  occur, 
resulting  in  a  fistula  of  the  duct  at  the  point  of  injury,  such 
as  wounds,  or  cuts  during  fights,  surgical  operations,  etc. 
In  sui^puration  about  the  glands  requiring  incision,  the 
duct  may  be  cut,  and  Shelly  reports  a  case  of  this  kind, 
while  Spitzka  reports  a  case  where  Stenson's  duct  was  di- 
vided during  excision  of  a  tumor  of  the  face.  In  fistula  of 
Stenson's  duct  the  orifice  is  usually  situated  over  the  buc- 
cinator muscle.  The  orifice  is  granular  and  surrounded 
by  cicatricial  tissue.  The  normal  fluid,  which  is  viscid, 
is  discharged  constantly,  but  in  increasing  quantity  during 
mastication.  A  small  blunt-iDointed  probe  can  usually  be 
passed  into  the  duct,  its  course  being  horizontally  back- 
ward and  inward. 

Treatment. — The  treatment  of  recent  cases  resulting 
from  clean  cuts  consists  in  adjusting  the  ends  with  catgut. 
The  wounds  usually  heal  if  properly  adjusted.  In  chronic 
cases  the  orifice  of  the  fistula  should  be  cauterized,  and  if 
there  is  an  oral  orifice  closure  will  usually  follow.  When 
this  is  absent  there  is  but  one  thing  to  do,  viz.,  to  reestablish 
an  internal  opening.  Agnew  suggests  an  effective  and  sim- 
ple method  of  closing  fistula  of  Stenson's  duct.  He  says: 
''Everting  the  cheek  with  the  thumb  on  the  inside  and  the 
fingers  on  the  outside,  a  curved  needle  armed  with  a  silk 
thread  is  carried  beneath  and  around  the  duct,  a  short  dis- 
tance posterior  to  where  it  ojoens  into  the  mouth,  both  the 
entrance  and  exit  of  the  needle  being  on  the  mucous  surface 


DISEASES    OF    THE    SALIVARY   GLANDS 


367 


of  the  mouth  and  not  deep  enough  to  reach  the  integument 
of  the  cheek.  The  needle  is  now  detached  from  the  thread, 
and  the  ends  of  the  latter,  after  being  tied  together,  are 
brought  out  of  the  corner  of  the  mouth  and  secured  to  the 
outside  of  the  face  by  a  strip  of  adhesive  plaster.  As  the 
thread  ulcerates  its  way  through  the  included  tissues,  the 
duct  is  separated  from  the  cheek,  causing  the  saliva  to  flow 


Fig.  180. — -Operation  for  Salivary  Fistula.  (Bryant.) 


Fig.  181. — Operation  for  Salivary  Fistula.  (Bryant.) 

into  the  mouth,  which  is  quickly  followed  by  closure  of  the 
fistulous  orifice  on  the  cheek." 

Other  methods  have  also  been  used.  Hartman  passes  a 
trocar  from  the  orifice  obliquely  forward  through  the  cheek, 
and  allows  it  to  remain  until  repair  has  taken  place. 

The  external  wound  is  closed  either  by  cauterization  or 
by  a  plastic  operation.  Eechelot  makes  a  double  puncture 
— the  external  one  back  of,  and  the  internal  one  anterior  to, 
the  fistula.  It  includes  the  normal  duct  near  the  fistula. 
This  is  loaded  with  a  drainage  tube,  which  is  allowed  to 
remain  until  repair  takes  place. 

In  all  of  these  methods  the  object  is  to  establish  a  new- 
internal  orifice  and  close  the  external  opening.     The  tech- 


368  THE    SALIVARY    GLANDS 

nic  must  be  varied  slightly  to  suit  the  variations  in  dif- 
ferent cases. 

4.  Concretions  of  the  Glands  and  Ducts.— Salivary 
calculus  is  a  concretion  of  lime  salts,  principally  of  lacto- 
phosphate,  together  with  some  magnesia  and  soda.  The 
formation,  according  to  Burchard,  is  due  to  the  action  of 
lactic  acid  upon  the  salivary  secretion,  causing  a  coagTila- 
tion  of  mucin,  which  forms  the  meshwork  in  which  the  salts 
are  jDrecipitated.  Klebs  and  Waldyer  believe  that  masses 
of  microbes  are  the  most  common  cause  of  salivary  stones, 
the  phosphates  and  carbonates  of  lime,  magnesia  and  soda 
being  deposited  around  them ;  some  other  writers  think  that 
the  nucleus  is  a  foreign  body  introduced  into  the  duct  from 
the  mouth.  Many  are  of  the  opinion  that  the  formation  is 
due  to  a  systemic  condition  or  a  gouty  diathesis,  and  state 
that  calculi  are  also  present  in  the  kidneys  and  gall  bladder, 
and  that  in  the  great  majority  of  instances  salivary  calculi 
occur  in  individuals  who  have  calcareous  deposits  upon 
their  teeth.  The  calculi  are  deposited  in  concentric  layers, 
like  those  formed  in  the  kidney  and  gall  bladder,  and  have 
organic  centers,  which  furnish  evidence  in  favor  of  their 
bacterial  origin.  Fross  reports  a  case  from  which  three 
facet-shaped  stones  were  removed,  stating  that  facet-shaped 
calculi  are  very  rare. 

Salivary  calculi  are  seen  at  all  ages,  but  are  most  fre- 
quent between  the  ages  of  twenty-five  and  forty.  Moiseff 
reports  a  case  of  multiple  calculus  in  a  patient  aged  seventy, 
and  Wyeth,  one  in  a  girl  four  years  old,  in  both  of  which 
the  calculi  were  successfully  removed.  Bardel  reports  a 
removal  in  a  case  three  weeks  old. 

The  stones  vary  in  size,  the  size  depending  upon  the  age 
of  the  accumulation.  Clinton  Wagoner  removed  a  calculus 
which  weighed  931/2  grains,  and  Eagle  removed  one  weigh- 
ing 1,080  grains,  while  Robertson  removed  from  a  Bushman 
in  South  Africa  a  calculus  the  size  of  a  bantam's  egg.  In 
ninety-six  cases  that  the  author  has  been  able  to  collect. 


DISEASES    OF    THE    SALIVARY   GLANDS  369 

seventy-two  were  of  Wharton's  duct,  ten  of  the  submaxil- 
lary gland,  seven  of  the  sublingual  gland  and  duets,  and 
eight  of  Stenson's  duct  and  the  parotid  gland.  In  many 
reported  cases  the  location  is  not  given. 

Symptoms. — The  symptoms  are  not  always  acute,  but 
become  so  as  the  calculus  increases  in  size  so  as  to  become 
an  irritant,  when  inflammation  and  swelling  ensue  as  the 
result  of  metastatic  cellulitis,  beginning  on  one  side  of  the 
tongue,  extending  to  the  base  of  this  organ  and  about  the 
mandible  on  the  same  side.  The  swelling  extends  down 
along  the  neck.  The  presence  of  such  symptoms  is  evidence 
of  pyogenic  infection,  and  there  will  usually  follow  a  chill, 
high  temperature,  and  other  constitutional  symptoms,  such 
as  nausea,  loss  of  appetite,  etc.  When  acute  inflammation 
does  not  develop  the  symiotoms  are  confined  to  the  floor  of 
the  mouth.  As  the  calculus  increases  in  size,  the  tongue  is 
crowded  backward  and  to  the  opposite  side,  and  the  tume- 
faction is  observed  below  the  mandible.  In  almost  every 
case  obstruction  of  the  duct  occurs,  and  as  the  saliva  ac- 
cumulates the  case  presents  symptoms  of  simple  obstruc- 
tion, or  ranula.  On  palpation,  when  fluid  is  present,  the 
tumor  will  fluctuate,  and  pressure  will  generally  force  some 
of  the  contents  from  the  noiTQal  orifice  of  the  duct.  In 
Fross's  case  palpation  forced  out  a  few  drops  of  pus. 

The  first  symptom  of  calculus  of  Wharton's  duct  is  the 
presence  of  a  hard  lump  in  the  floor  of  the  mouth.  A  diag- 
nosis must  be  made  from  ranula,  which  is  a  simple  obstruc- 
tion of  the  duct,  from  benign  or  malignant  tumors,  cysts, 
tuberculous  glands  and  cellulitis  with  supiouration.  One 
case  was  sent  to  a  hospital  for  a  tongue  amputation,  another 
presented  erosion  resembling  epithelioma  and  many  are 
mistaken  for  malignant  diseases  of  the  glands. 

The  one  procedure  which  is  without  danger,  when  prac- 
ticed under  strict  antiseptics,  is  to  pass  a  fine  sewing  needle 
into  the  mass.  This  may  be  thrust  in  at  several  places,  so 
as  thoroughly  to  explore  the  tumor.     In  making  such  an 


370  THE    SALIVARY    GLANDS 

exploration  a  knowledge  of  anatomy  is  necessary,  for  blood 
vessels,  nerves,  etc.,  should  not  be  injured.  The  needle  will 
impart  to  the  experienced  touch  the  presence  of  the  concre- 
tion. Before  making  a  puncture  of  the  tumor  with  a  needle, 
an  effort  should  be  made  to  probe  the  duct.  If  this  can  be 
done,  the  probe  will  pass  up  to  the  calculus  and  confirm  a 
diagnosis. 

Treatment. — Treatment  consists  in  the  removal  of  the 
calculus  through  the  oral  mucous  membrane.  The  incision 
is  made  with  a  small  finger  knife  over  the  most  superficial 
part  of  the  tumor,  and  should  be  sufficiently  large  to  remove 
it.  The  practice  of  dilating  the  duct  is  not  to  be  depended 
upon  unless  the  stone  is  found  near  the  orifice.  Extra  open- 
ings into  a  duct  along  its  course  are  of  no  consequence. 
When  the  calculi  are  in  the  gland,  or  when  they  are  well 
back  in  Stenson's  duct,  it  is  not  always  possible  to  remove 
them  through  the  mouth.  In  such  cases  an  external  opera- 
tion will  be  necessary.  The  skin  incision  should  not  be 
made,  however,  unless  it  is  impossible  to  operate  through 
the  mouth,  since  a  salivar}^  fistula  is  usually  the  result. 
After-treatment  is  of  little  consequence,  since  all  active 
symjDtoms  will  subside  in  the  course  of  a  few  days. 

5.  Obstructions  of  the  Ducts  Other  Than  Concretions. 
— Other  obstructions  of  the  salivary  glands  causing  patho- 
logical conditions  are  of  three  varieties: 

1st.  Congenital  defects,  generally  an  imperforate 
Wharton's  duct. 

2d.  Obstructions  due  to  the  entrance  of  foreign  sub- 
stances into  the  duct.  Several  cases  are  on  record  where 
fish  bones  have  been  introduced  into  the  orifice  of  the  duct, 
resulting  in  suppuration  or  simple  accumulation  or  ranula. 
Overall  reports  a  case  of  the  passage  of  a  hair  into  Sten- 
son's duct,  causing  an  obstruction  resulting  in  external 
abscess  and  fistula. 

3d.  Laceration  of  the  duct  from  injuries,  the  cicatrix 
causing  obstruction.    Sinne  reports  a  case  of  this  kind  fol- 


DISEASES    OP    THE    SALIVAEY   GLANDS  371 

lowed  by  inactivity  of  the  corresponding  parotid  gland.  As 
there  were  present  no  signs  of  either  fistula  or  abscess — 
complications  which  were  anticipated — Sinne  concluded 
that  the  parotid  gland,  owing  to  the  continued  pressure, 
became  hermetically  sealed  by  the  union  of  the  flap  to  the 
underlying  jDart  and  ceased  activity,  in  time  probably  under- 
going atrophy  because  of  non-use.  The  jDatient  did  not  com- 
plain of  pain  or  other  ailment,  and  was  to  all  appearances 
perfectly  well.  This  case  simply  compels  us  to  conclude 
that  it  is  best  to  postpone  surgical  interference  in  all  simi- 
lar cases.  A  case  is  also  recorded  where  the  jDressure  of  a 
hard  apple  against  the  floor  of  the  mouth  caused  an  acute 
congestion  of  Wharton's  duct  and  accumulation  of  saliva. 

Eanula. — Ranula  is  an  accumulation  of  the  normal 
fluids  of  some  of  the  glands  accessory  to  the  oral  cavity  as 
a  result  of  obstruction  of  the  duct.  It  is  usually  of  the  ducts 
of  the  submaxillary  or  the  sublingual  glands.  Wolfer  re- 
ports a  ranula,  due  to  the  obstruction  of  the  excretory  duct 
of  the  glands  of  Nuhn,  in  a  child  nine  months  old.  It  was 
the  size  of  a  pecan,  was  situated  under  the  side  of  the 
tongue,  and  contained  whitish-green  protoplasmic-like  fluid 
filled  with  plate  epithelium.  Ranula  must  be  differentiated 
from  dermoid  cysts  and  lymphangioma.  Ranula  may  be 
congenital  or  it  may  develop  at  any  time  during  life. 

N.  Muller,  of  Moscow,  states  that  he  has  seen  five  cases 
of  congenital  ranula  in  80,000  children  in  seven  years.  Sir 
W.  Ferguson,  Dubois,  and  Lombard  re^Dort  one  case  each, 
while  Bryant  has  seen  two. 

Since  saliva  is  not  secreted  in  fetal  life,  it  is  thought  that 
these  so-called  congenital  ranulae  are  either  obstructions  of 
the  ducts  of  the  glands  of  Nuhn,  or  accumulations  in 
Fleischman's  bursa.  Others  think  they  are  dermoids.  In 
a  pajDer  by  Dr.  Richard  von  Hippel  (Berlin)  he  discusses 
and  criticises  the  various  theories  which  have  been  ad- 
vanced to  explain  the  origin  of  ranulse.  The  careful  macro- 
scopic and  microscopic  examinations  of  numerous  speci- 


372 


THE    SALIVARY    GLANDS 


mens  leads.  Mm  to  very  positive  ideas  on  tlie  subject.  He 
agrees  with  Neumann  and  others  that  certain  ranul^  arise 
from  unobliterated  portions  or  branches  of  the  thyro-glos- 
sal  duct,  and  reports  one  interesting  and  thoroughly  con- 
vincing case  in  sup]jort  of  this  view.  To  anyone  who  has 
stndied  true  median  cervical  fistula,  the  conception  of  such 
an  origin  presents  no  difficulties.    Most  cases  of  ranula  have 


Fig.  1S2. — Model  of  Raxula  Before  Operation. 

another  origin.  In  .-tudying  this  subject  von  Hippel  makes 
free  use  of  the  excellent  researches  of  Suzann.  with  whose 
views  he  largely  agrees. 

A  rare  case  of  double  acute  rnnuJa  is  reported  by  Carre. 
He  was  called  to  attend  a  man  who  felt  somethins"  suddenly 
form  in  his  mouth  whir'li  was  nearly  suffocating  him.  AVhen 
he  arrived  he  found  the  mnuth  occupied  by  two  large  oval 
swellings  of  a  pale,  pinkish  color  with  translucent  walls; 
the  tongue  was  displaced  backward  over  the  glottis,  oc- 
casioning severe  dyspnea  and  com]ilr:-te  inability  to  swallow. 


DISEASES    OF    THE    SALIVARY   GLANDS  373 

On  the  right  side  swelling  was  also  present  below  the  angle 
of  the  jaw.  The  patient  had  just  begun  dinner,  having  pre- 
viously been  in  excellent  health,  when  his  mouth  suddenly- 
filled  up  with  the  tumor  below  the  tongue,  which,  rapidly 
increasing,  pushed  the  tongue  backward  so  that  only  the 
under  surface  of  the  tip  was  visible  on  examination.  There 
was  nothing  in  the  diet  to  account  for  the  symptoms,  and 


Fig.  183. — Ranula  Showing  Incision. 

no  calculi  or  stenoses  of  Wharton's  duct  could  be  discov- 
ered.    A  free  incision  was  made,  which  gave  exit  to  one 
and  one-half   ounces   of  a   fluid  which  resembled   saliva. 
Relief  prom^^tly  followed. 

The  location  of  the  tumor  in  all  varieties  varies  within 
somewhat  wide  limits.  Generally  it  is  near  the  frenum  and 
grows  outward  and  backward ;  sometimes  it  spreads  toward 
the  other  side,  and  so  appears  median.  In  other  cases  the 
tumor  is  from  the  first  distinctly  lateral  and  never  ap- 


374 


THE    SALIVARY    GLANDS 


proaches  close  to  the  middle  line.  All  these  peculiarities 
are  siraj^le  when  the  topography  of  the  sublingual  gland  is 
considered,  and  depend  on  the  part  of  the  gland  attacked 
by  the  chronic  interstitial  inflammation.  If  both  glands  are 
attacked  by  this  inflammation,  cysts  will  develop  more  or 
less  symmetrically  on  both  sides  of  the  frenum.  Occasion- 
ally, but  rarely,  cysts  are  truly  median,  and  may  lie  close 
to  the  alveolus  of  the  jaw.    In  these  cases  it  is  not  the  sub- 


FiG.   184. — Sarcoma  of  the  Parotid   Gland.     (Collection  of   Dr.   Charles 

McBurney.)    (Johnson.) 

lingual  but  the  "incisor  glands"  which  are  diseased.  (The 
grandula  incisiva  lies  in  the  middle  line  of  the  floor  of  the 
mouth,  immediately  behind  the  incisor  teeth.) 

Treatment. — The  treatment  of  ranula  consists  in  the 
evacuation  of  the  cyst  by  incision,  and  the  establishment  of 
an  orifice,  so  that  the  fluid  secreted  by  the  gland  may  be 
permitted  to  escape  into  the  oral  cavity  as  it  makes  its 
escape  from  the  gland.  The  method  of  operation  is  to  in- 
cise the  sac  from  end  to  end  or  to  make  the  opening  so  large 


DISEASES    OF    THE    SALIVARY   GLANDS  375 

that  it  cannot  close  during  repair,  thus  making  the  cavity 
of  the  sac  a  part  of  the  oral  cavity.  The  mucous  membrane 
and  the  wall  of  the  sac  are  sutured  throughout  with  ten- 
day  catgut  to  i^revent  closure.  Other  methods  of  treat- 
ment have  been  introduced.  Chlorid  of  zinc  in  solution  has 
been  injected  into  the  cavity,  but  this  method  is  not  rational, 
since  it,  as  well  as  other  caustic  injections,  may  obliterate 
the  sac  and  cause  accumulation  of  the  fluid  farther  back. 

6.  Malignant  Growths.— Malignancy  of  the  salivary 
glands  does  not  require  special  attention  here.  Sarcoma 
and  carcinoma  are  considered  in  detail  in  the  chapter  on 
Tumors. 

Tuberculosis  of  the  salivary  glands  is  not  so  common  as 
malignant  diseases.  It  does  occur,  and  Frederick  Kam- 
merer  reports  a  case  in  which  the  patient,  a  woman,  had 
tuberculosis  of  both  elbows.  A  tumor  was  removed  from 
the  side  of  the  neck,  which,  upon  microscopic  examination, 
proved  to  be  tuberculous. 

For  further  consideration  of  tumors  and  tuberculous 
diseases  of  the  salivary  glands  the  reader  is  referred  to  the 
chapter  on  these  subjects. 


CHAPTER   XXXIII 

ANKYLOSIS 

Ankylosis  is  an  impairment,  from  any  cause,  of  the 
functional  usefulness  of  a  joint.  Ankylosis  of  the  temporo- 
maxillary  articulation  is  of  special  interest  to  the  dentist, 
since  free  movement  at  this  point  is  necessary  if  any  dental 
operation  of  importance  is  to  be  performed  unimpeded. 

For  convenience  of  study,  the  several  kinds  of  ankylosis 
may  be  tabulated  as  follows : 

Temporary : 

From  tooth  eruptions  and  impactions. 

From  inflammations  of  adjacent  soft  structures. 

From  tuberculous  and  other  bone  diseases. 
Permanent : 

Fibrinous. 

Osseous. 

TEMPORARY  ANKYLOSIS 

In  temporary,  or  spasmodic,  ankylosis,  due  to  the  non- 
eruption  of  the  last  lower  molar,  or  to  the  pain  associated 
with  late  eruption,  the  removal  of  the  offending  tooth  will 
be  followed  by  disappearance  of  symptoms.  Erupting  teeth 
may  cause  rigidity  of  the  muscles,  which  disappears  when 
the  mucous  membrane  overlying  the  tooth  is  removed, 
either  by  operation  or  naturally. 

Inflammatory  disturbance  of  the  soft  structures,"  such 
as  inflammation  of  the  parotid  gland,  cellulitis  or  abscesses 
involving  the  masseter  or  temporal  muscles,  is  an  occasional 
cause.  When  the  inflammatory  trouble  subsides  the  func- 
tional usefulness  is  restored  if  the  destruction  has  not  been 

376 


TEMPORARY  ANKYLOSIS  377 

extensive  or  has  not  changed  the  normal  relationship  of 
parts. 

Tuberculous,  syphilitic,  or  other  destructive  diseases  of 
the  bones  which  give  origin  or  insertion  to  the  muscles  of 
mastication,  also  limit  the  motion  of  the  mandible  during 
activity.  In  a  case  recently  under  treatment  the  motion  was 
limited  to  two-thirds  of  the  normal  range,  as  a  result  of 


Fig.  185. — Impacted  Thikd  Upper  Molar,  in  a  Boy  Aged  About  15,  Causing 
Spasmodic  Ankylosis. 

periostitis  of  the  internal  surface  of  the  ramus  of  the  man- 
dible, and  continued  to  be  so  until  the  sinus  caused  by  oper- 
ation for  the  removal  of  a  sequestra  had  closed.  Alveolar 
abscesses  and  osteitis  following  infection  have  as  an  almost 
constant  symptom  a  limited  range  of  motion.  As  has  been 
stated  in  the  chapter  on  Tuberculosis,  the  one  ever-present 
symptom  is  muscular  spasm,  producing  a  rigid  joint.  This 
must  always  be  taken  into  account  in  computing  ankylosis 
and  predicting  the  final  outcome.    Burns  involving  deeper 


378  ANKYLOSIS 

structures  quite  frequently  produce  limited  raotion  of  the 
mandible. 

Illustrative  Cases.— Figure  185  shows  the  case  of  a  hoy 
about  fifteen  or  sixteen  years  old,  who  was  suffering  with 
temporary  ankylosis  of  the  jaw,  for  which  no  apparent  cause 
could  be  found.  While  it  was  known  that  his  molars  had  not 
erupted,  there  was  but  slight  irritation  in  this  region.  An 
X-ray  picture,  however,  showed  that  the  upper  third  mo- 
lar, instead  of  developing  in  the 
proper  direction,  was  tilted  and 
pressing  upon  the  root  of  the  sec- 
ond molar.  After  its  removal,  the 
spasmodic  ankylosis  entirely  dis- 
apjDeared,  and  the  boy  became  per- 
fectly well. 
T^      ,^a     T  rn  Figure  186   shows   several  ir- 

FiG.  186. — Impacted    Third  ®  .   . 

jNIolae  Causing   Spasmodic  regularities,  the  principal  one  an 
-KYLosis.  impacted  upper  third  molar.    The 

symptom  was  the  inability  of  the  patient  to  open  the  mouth 
properly,  temporary  ankylosis  being  due  to  reflex  spasms. 
Eemoval  of  the  offending  tooth  resulted  in  complete  relaxa- 
tion of  the  muscular  spasm. 

Treatment.— The  treatment  depends  upon  the  cause, 
and  a  proper  diagnosis  is  of  paramount  importance.  If 
the  condition  is  due  to  delayed  eruption,  encourage  eruption 
by  scoring  the  gum,  or  by  removing  a  square  of  tissue  from 
over  the  cro^^m..  If  to  an  encysted  tooth,  chisel  away  the 
bone,  and  remove  the  tooth.  If  to  necrosis,  remove  the  dead 
bone,  or  at  least  curette  the  part  thoroughly.  If  to  syphilis, 
medicate  as  outlined  in  the  chapter  on  that  subject.  The 
removal  of  the  cause  will  be  followed  by  relief. 

PERMANENT  ANKYLOSIS 

Chronic,  true,  or  permanent  occlusion  may  be  due  to 
cicatrical  contractions  of  the  muscles  of  mastication  and 


PERMANENT    ANKYLOSIS  379 

the  surrounding  soft  parts,  when  it  is  known  as  incomplete 
or  false  occlusion,  or  to  a  destruction  of  the  temporo-max- 
illary  joint,  when  it  is  known  as  true  ankylosis.  In  the 
former,  the  conditions  producing  the  limitation  of  motion 
are  abscesses  or  inflammations  of  the  tissues  about  the 
ramus,  resulting  after  repair  in  a  shortening  of  the  tissues 
between  the  zygomatic  arch  or  the  squamous  portion  of  the 
temporal  bone,  or  pterygoid  plates  of  the  sphenoid  bone 
above  and  the  mandible  below.  Gangrenous  stomatitis, 
syphilitic  lesions  with  destructive  salivation  beginning  in 
the  mucous  membrane  are  causes  of  occlusion.  Surgical 
operations  and  lacerations  of  these  parts  are  followed  by 
cicatricial  contraction  of  the  structures  and  impairment  of 
free  motion  of  the  mandible. 

The  most  common  variety  of  true  ankylosis  is  due  to 
destruction  of  the  temporo-mandibular  joint.  The  causes 
are  rheumatoid  arthritis,  when  the  ankylosis  is  gen- 
erally associated  with  a  similar  affection  of  other  joints 
throughout  the  skeleton,  and  gonorrhea,  which  has  been 
known  to  produce  ankylosis  of  this  joint  by  secondarily 
producing  a  synovitis  of  the  joint  followed  by  destruc- 
tion. 

Otitis  media  resulting  in  destruction  of  the  bone  in  front 
of  the  meatus  results  in  infection  of  the  temporo-mandibu- 
lar joint,  followed  by  destruction  and  ankylosis.  This  is 
quite  a  common  cause  of  osseous  ankylosis. 

Treatment. — The  treatment  for  contraction  of  cicatricial 
tissue  following  scarlatina,  ulcerations,  injuries,  and  ab- 
scesses, is  not  at  all  times  satisfactory.  Two  methods  are 
recommended:  (a)  by  the  formation  of  a  pseudoarthrosis 
anterior  to  the  attachment  of  the  cicatricial  tissue,  and  (b) 
by  the  severing  or  removal  of  the  scar  tissue.  For  the 
former  the  reader  is  referred  to  the  methods  described  for 
permanent  occlusion.  Section  is  done  by  simple  subcu- 
taneous incision,  with  a  small  tenotome,  of  all  shortened 
tissues  that  resist  an  effort  toward  opening  the  mouth.   The 


380  ANKYLOSIS 

entire  cicatricial  area  is  dissected  away.  Neither  of  these 
methods  is  entirely  reliable. 

The  treatment  of  permanent  osseous  occlusion  consists 
in  an  effort  toward  the  formation  of  a  pseudoarthrosis  at 
a  point  which  will  afford  the  best  functional  usefulness  of 
the  mandible.  If  the  joint  has  been  destroyed  by  fibrous 
adhesions,  daily  use  of  a  screw-gag  up  to  tolerance  will  in- 
crease the  range  of  motion  in  many  cases,  and  this  method 
should  be  tried  before  major  operation  is  practiced.  Pas- 
sive motion  may  also  be  carried  out  with  a  screw  incline. 
Before  the  use  of  any  form  of  mechanical  apparatus  to 
force  the  jaws  apart,  the  teeth  should  be  protected  with  a 
strip  of  lead  or  gutta-percha  plates,  as  the  enamel  may  be 
chipped,  defacing  a  normal  tooth.  When  the  method  just 
described  does  not  avail,  an  anesthetic  should  be  adminis- 
tered and  great  force  used  to  break  up,  if  possible,  the  ad- 
hesions between  the  condyle  and  the  temj^oral  bone.  Little 
damage  can  be  done  if  care  is  taken  not  to  force  the  teeth 
farther  apart  than  a  normal  distance,  or  possibly  slightly 
more.  If  the  effort  is  successful,  the  mouth  should  be  held 
open  with  a  cork  or  other  substance  secured  between  the 
teeth  by  a  ligature,  which  may  be  anchored  to  the  teeth. 
In  forty-eight  hours  the  gag  may  be  removed,  passive  mo- 
tion practiced,  and  a  slightly  smaller  gag  inserted.  Daily 
passive  motion  must  be  done  just  as  soon  as  the  soreness 
sufficiently  subsides  to  permit  of  it. 

Ditfenbach  was  the  first  to  recommend  and  practice  the 
formation  of  a  false  joint  in  the  mandible  for  the  reestab- 
lishment  of  mandibular  motion.  Esmarch  recommended 
that  a  V-shaped  section  be  removed  from  the  bone.  Riz- 
zole  was  first  to  state  that  the  false  joint  should  be  anterior 
to  the  cicatricial  band  causing  the  occlusion.  Helferick 
recommends  resection  of  the  condyle  and  reports  successes, 
as  does  Lentz  by  the  same  method.  The  internal  maxillary 
artery  should  be  ligated  to  prevent  hemorrhage  after  the 
operation.    Arbuthnot  Lane,  of  London,  reports  four  cases 


PERMANENT    ANKYLOSIS 


381 


successfully  treated  by  this  method,  and  states  that  failure 
follows  insufficiently  free  removal  of  bone.  All  of  these 
operators  interpose  a  portion  of  the  masseter  muscle  or  fas- 
cia between  the  cut  surface  of  bone  to  prevent  union.  El- 
liott, of  Boston,  reports  success  following  resection  of  the 
condyles  in  a  boy  aged  twelve. 

Recently  the  Gigli  wire  saw  has  been  introduced,  which 


Fig.  187. — Resection  of  the  Mandibular  Condyle.     (After  Roe.) 

takes  the  place  of  all  other  methods  in  making  section 
through  bones  in  deep  structures.  It  is  flexible,  cuts  on  all 
sides,  and  can  be  passed  around  a  bone  through  a  skin 
wound  of  small  size. 

Pneumonia,  typhoid  fever  and  the  exanthemas  have 
caused  osseous  ankylosis.  In  the  following  case  the  cause 
was  smallpox. 

Case  Report. — The  patient  was  forty-four  years  old 
when  operated  upon.  When  eight  years  of  age  he  had 
smallpox,    resulting   in   complete    ankylosis    of   the    right 


382  ANKYLOSIS 

temporo-mandibular  articulation,  with  no  motion,  and  the 
approximation  of  the  teeth  was  so  complete  that  the  crowns 
of  the  cuspids  and  the  bicuspids  had  ulcerated  through  the 
gums,  covering  the  opposite  process.  He  was  compelled  to 
live  on  liquids  or  to  force  solid  particles  of  food  through 
between  the  teeth,  yet  he  was  well  nourished  and  had 
worked  at  his  trade  as  a  boiler-maker  for  years,  with  com- 


FiG.  188. — Resection  of  Mandible,  Showing  Gigli  Saw  in  Position. 

parative  health  and  strength.  In  order  that  as  little  scar 
as  possible  might  result  from  the  operation,  an  incision  one- 
half  inch  long  was  made  immediately  under  the  angle  of  the 
mandible,  parallel  to  it,  and  in  front  of  the  facial  artery.  A 
Gigli  saw  was  passed  into  the  mouth,  internal  to  the  man- 
dible. The  lips  were  retracted  so  as  to  prevent  their  lacer- 
ation while  sawing.  The  bone  was  cut  through.  The  mouth 
was  easily  forced  wide  open,  the  joint  on  the  left  side  re- 
maining in  a  practically  normal  condition  after  having  been 
fixed  for  thirty-six  years.    To  prevent  motion  between  the 


PERMANENT    ANT^YLOSIS 


383 


several  ends  of  the  bone,  about  half  an  inch  of  the  posterior 
fragment  was  broken  off  with  forceps.  The  cavity  was 
filled  with  sterile  gauze  to  prevent  approximation.  The 
packing  was  removed  and  repacked  every  second  day  for 
several  weeks.  The  second  figure  shows  result.  (Figure 
189.) 

So  far  as  the  author  has  been  able  to  learn,  four  opera- 
tions for  ankylosis  of  the  mandible  by  section  of  the  rami 


Fig.  189. — Result  of  Resection. 

have  been  reported:  the  first  by  Dr.  AVayne  Babcock,  the 
second  and  third  by  Dr.  Blair,  the  fourth  by  Dr.  Cathcart 
and  Dr.  Solomons,  of  Charleston,  S.  C. 

A  fifth  case  is  herewith  recorded. 

A  boy,  when  four  years  of  age,  fell  down  a  balustrade, 
striking  his  chin  against  the  floor  and  fracturing  the  man- 
dible in  several  places,  resulting  in  complete  ankylosis  of 
the  jaw  so  that  the  deciduous  teeth  were  extracted  and  the 
permanent  teeth  came  in  without  any  regard  to  normal 
growth,  owing  to  the  pressure. 

At  the  age  of  twenty-seven,  or  twenty-three  years  after 


384 


ANKYLOSIS 


Fig.  192. 
Figs.  190-192. — Incision  Through  Skin  and  Needle  Passing  Under  Maxilla 
Into  Mouth.  Fig.  190. — Method  of  introducing  pedicle  needle,  with  eye 
in  the  end  threaded  so  as  to  be  withdrawn  through  the  mouth,  and  for  the 
purpose  of  drawing  the  Gigh  saw  through  back  of  the  bone.  Fig.  191. — 
Gigh  saw  in  position,  showing  method  of  sawing  through  the  bone,  with  the 
mouth  retracted  so  that  the  saw  does  no  damage  to  the  soft  tissues.  Fig. 
192. — Severed  jaw  advanced  to  the  position  where  it  is  to  be  held  to  the  up- 
per teeth  with  Angle's  bands  and  wires. 


PERMANENT    ANTKYLOSIS  385 

the  accident,  it  was  possible  to  get  a  silver  ten-cent  piece 
between  some  of  the  teeth,  but  there  was  absolutely  no  mas- 
ticating power.  The  chin  had  so  far  receded  that  the  gingi- 
val margin  in  the  median  line  below  was  five-eighths  of  an 
inch  back  of  the  incisors  above.  This  was  the  one  point  of 
entrance  for  food,  and  he  had  lived  on  soft  foods,  especially 
prepared,  during  the  twenty-three  years. 

The  operation  consisted  in  making  an  incision  immedi- 


FiG.  193. — Case  Before  Operation.  Front  View. 

ately  below  the  lobes  of  the  ear  as  shown  in  figure  191,  down 
to  the  parotid  gland.  Owing  to  the  fact  that  the  space  nor- 
mally found  betw^een  the  ramus  and  the  mastoid  was  ob- 
literated by  the  displacement  of  the  bone,  the  parotid  gland 
was  found  resting  upon  the  external  surface  of  the  ramus. 
The  gland  was  carefully  dissected  away  from  the  masseter 
muscle,  and,  along  with  the  seventh  nerve  and  Stenson's 
duct,  which  are  included  in  it,  were  all  pushed  upward  and 


386 


ANKYLOSIS 


held  there  by  retraction.  A  long  curved  pedicle  needle, 
bent  almost  at  a  right  angle  with  the  shaft,  was  pushed 
around  back  of  the  ramus  underneath  the  bone  and  forward 
into  the  oral  cavity  immediately  back  of  the  molar  teeth. 
The  needle  has  an  eye  at  the  end.  This  was  threaded  and 
with  a  hook  the  thread  was  pulled  out  into  the  mouth.  A 
Gigli  saw  was  now  drawn  through  back  of  the  bone  and 


1 

PI 

^^^^^L,^  / 

■ 

fn 

^       9 

^^^HH^> 

^^H 

1 

11 

K 

1 

1 

ll 

a 

Fig.  194. — Case  Before  Operation.  Side  View. 

with  the  retractor  (figure  191)  the  angle  of  the  mouth  was 
drawn  back,  so  as  not  to  do  any  damage  to  the  cheek.  The 
bone  was  now  severed  by  the  Gigli  saw,  one  end  passing 
through  the  mouth  and  the  other  through  an  incision  below 
the  ear.  The  incision  through  the  skin  was  about  one  inch 
long.  The  other  side  was  operated  on  in  the  same  way. 
When  the  bone  was  cut  off  on  the  second  side  it  dropped 
away  from  the  upper  teeth  fully  an  inch,  and  was  freely 
movable  in  every  direction.  It  is  necessary  in  this  opera- 
tion to  avoid  the  carotid  artery  and  the  cranial  nerves, 
which  pass  down  from  the  base  of  the  skull  at  this  point. 


PERMANENT    ANKYLOSIS 


387 


This  was  done  by  hugging  the  bone  closely  as  the  needle 
passed  around  underneath  into  the  mouth.  A  pair  of  these 
needles  are  necessary,  since  the  curve  is  different  on  the  two 
sides. 

Several  problems  naturally  present  themselves.     The 
first  is  the  question  of  nutrition  for  the  body  of  the  bone 


Fig.    195. — Case   After   Operation. 
Incision  and  advancement  of  jaw. 


Fig.   196. — Case  After   Operation. 
Mouth  open. 


after  both  inferior  dental  arteries  are  destroyed.  It  must 
be  remembered  that  the  nutrition  of  the  bone,  while  par- 
tially from  these  arteries,  is  not  wholly  so,  and  that  with 
their  destruction  the  periosteum  will  take  up  the  work  of 
thoroughly  nourishing  the  entire  bone,  including  the  teeth. 
The  dentist  naturally  wonders  whether  the  withdrawal  of 
the  blood  supply  to  the  teeth  through  their  apices  will  not 
result  in  dental  caries.  So  far  as  has  been  observed  at  this 
time,  about  six  months  from  date  of  operation,  the  teeth 


388  ANKYLOSIS 

are  thorouglily  nourished  and  there  is  no  eviderce  of  these 
complications.  As  to  the  nerve  supply,  the  only  impair- 
ment of  nerve  function  evidenced  is  some  numhness  over 
the  symphysis,  and  this  is  not  at  all  troublesome.  A_  per- 
manent functional  joint,  following  section  of  the  mandible 
where  the  bone  is  not  advanced  so  that  the  cut  ends  com- 
pletely pass  each  other,  is  hardly  to  be  expected,  but  while 
there  is  for  a  time  almost  perfect  functional  usefulness,  it 
has  been  the  experience  of  operators  that  the  cicatrices 
formed  around  the  end  of  the  bone  to  some  extent  interfere 
with  free  motion.  For  this  reason  it  is  very  desirable  that 
during  the  operation  sufficient  bone  be  removed  to  jDrevent 
union  between  the  fragments. 

Hysterical  occlusion  is  a  condition  occasionally  seen. 
Diagnosis  is  not  easj?",  and  the  skill  of  the  surgeon  is  tested. 
When  there  is  doubt  an  anesthetic  should  be  administered, 
and  if  the  case  is  neurotic  the  joint  will  be  freely  movable. 


CHAPTER  XXXTV 

FEACTURE    IN    GENERAL 

Fracture  is  a  sudden  and  violent  solution  of  continuity 
of  bone  into  two  or  more  fragments.  Fractures  constitute 
one-seventh  of  all  injuries.  Three  times  as  many  cases 
occur  in  males  as  in  females.  Fractures  are  most  common 
in  infants  and  after  fifty  years  of  age.  In  middle  life  there 
are  ten  times  as  many  cases  in  men  as  in  women. 

Varieties. — The  varieties  are:  simple  or  closed,  when 
the  skin  is  not  open;  compound  or  open,  when  the  skin  is 
torn  and  there  is  atmospheric  communication;  complete, 
where  the  bone  is  broken  entirely  across ;  incomplete  where 
the  break  is  not  entirely  through,  called  green  stick  or  in- 
fraction; single,  when  but  one  bone  is  broken;  multiple, 
when  there  is  more  than  one  point  of  fracture ;  comminuted, 
when  the  bone  is  broken  into  many  pieces;  complicated, 
when  important  structures  are  injured  at  the  time  of  frac- 
ture, such  as  blood  vessels,  nerves,  viscera,  brain,  etc. ;  im- 
pacted, when  one  bone  is  driven  into  another;  congenital, 
when  resulting  from  violence  during  intrauterine  life,  as 
from  external  violence,  uterine  contractions,  malformations, 
syphilis,  etc.;  obstetric,  when  produced  during  the  act  of 
delivery;  spontaneous,  when  the  result  of  very  slight  vio- 
lence in  fragile  bones,  caused  by  disease  or  tumor;  patho- 
logical, when  predisposed  by  disease  of  the  bone ;  ununited, 
where  there  is  no  union;  delayed  union,  where  the  bones  fail 
to  unite  at  the  usual  time,  but  unite  subsequently. 

Diastasis,  or  epiphyseolysis,  is  a  separation  of  an  epiphy- 
sis from  the  shaft  at  the  diaphysoepiphyseal  line.  It  occurs 
in  the  young  before  ossification. 

389 


390  FRACTURE    IN    GENERAL 

•  Fractures  may  occur  through  a  bone  in  the  following  di- 
rections: transverse,  when  the  break  is  at  a  right  angle  with 
the  long  axis  of  the  bone;  oblique,  when  it  passes  across  the 
bone  in  an  oblique  direction ;  longitudinal,  when  the  bene  is 
split  lengthwise;  spiral,  when  the  break  passes  spirally 
around  the  bone ;  stellate,  when  the  lines  of  fracture  radiate 
in  several  directions  from  a  common  point,  as  of  the  skull 
or  patella;  dentated  or  serrated,  when  the  line  of  fracture 
is  irregular. 

The  displacements  of  fragments  in  a  fracture  may  be: 
lateral,  when  the  ends  are  displaced  to  one  side ;  angidar, 
when  the  long  axis  is  bent;  rotary,  when  the  extremity  is 
twisted  or  rotated;  longitudinal,  when  the  ends  are  disen- 
gaged at  the  point  of  fracture  and  the  extremity  is  either 
shortened  or  lengthened. 

Etiology.— The  causes  of  fracture  are  usually  divided 
into  predisposing  and  exciting.  Predisposing  causes  are 
seoc,  age,  previous  diseases,  and  prominence  of  parts.  Ex- 
citing causes  are  external  violence,  which  may  be  either 
direct,  when  the  bone  is  broken  where  the  violence  is  re- 
ceived, or  indirect,  when  the  violence  is  received  at  a  point 
remote  from  the  point  of  fracture,  as  a  Colles'  fracture, 
resulting  from  a  fall  on  the  hand,  or  fracture  of  the  clavi- 
cle, resulting  from  violence  upon  the  shoulder ;  and  muscu- 
lar action,  also  a  form  of  indirect  violence,  which  may  pro- 
duce a  fracture  of  a  long  bone,  as  fracture  of  the  femur, 
caused,  while  running,  by  the  powerful  quadriceps  femoris. 

Symptoms.  — The  symptoms  may  be  subjective  or  object- 
ive. The  first  are  pain,  in  proportion  to  the  trauma  and 
nerve  involvement ;  loss  of,  or  diminished,  function,  in  pro- 
portion to  the  importance  of  the  bone  fractured;  shock, 
depending  upon  the  complications.  The  objective  symp- 
toms are  deformity,  which  may  be  swelling  caused  by  the 
hemorrhages  and  transfusion,  or  due  to  displacement  of  the 
bones  at  the  point  of  fracture,  which  may  be  angular,  lat- 
eral,  rotary,   shortening,   lengthening   or  impaction;   and 


PEOGNOSIS    OF    FRACTURE  391 

crepitation,  a  most  constant  and  very  valuable  sign,  caused 
by  the  fractured  ends  of  the  bone  coming  into  contact  dur- 
ing manipulation  or  movements.  This,  however,  is  absent 
in  impaction  and  diastasis. 

Diagnosis.— Diagnosis  depends  usually  upon  crepita- 
tion, loss  of  function  and  preternatural  mobility,  the  three 
cardinal  symptoms.  To  these  must  be  added  the  history 
of  the  injury,  pain,  swelling,  and  other  injury  to  the  soft 
parts.    The  X-ray  should  be  used  if  necessary. 

Prognosis.— Prognosis  is  usually  good  except  in  ad- 
vanced life.  Diseases  such  as  syphilis,  tuberculosis,  etc., 
interfere  with  repair. 

Complications  of  fracture  are  rupture  of  a  blood  ves- 
sel, laceration  of  nerves  and  lymphatics,  involvement  of 
joints,  emphysema,  embolism,  etc.  Compound  fracture, 
when  it  occurs,  is  always  a  complication  and  frec^uently 
leads  to  bacterial  invasion  (infection)  and  subsequent  sup- 
puration, cellulitis,  malignant  edema,  etc. 

Repair  of  bone  after  fracture  uniformly  occurs,  and 
requires  from  five  to  eight  weeks.  Eepair  is  the  result  of 
the  deposit,  about  the  ends  of  the  fractured  bones,  of  re- 
parative products,  which  eventually  ossify.  The  injury 
produces  laceration  of  the  periosteum  and  other  tissues, 
resulting  in  hemorrhage  from  torn  vessels,  extravasation, 
hyperemia,  cellular  exudation,  osteoporosis,  and  architec- 
tural reconstruction. 

Callus  is  usually  called  (a)  external,  or  that  developed 
from  periosteum;  (b)  internal,  or  that  developed  from  the 
endosteum  within  the  medullary  canal;  and  (c)  intermedi- 
ate, or  that  between  the  ends  of  the  broken  bone. 

The  bloodclot  that  fills  the  spaces  about  the  ends  of  bone 
is  displaced  in  a  few  days  by  leucocytes,  which  in  turn  are 
displaced  by  the  osteoblasts,  in  which  are  deposited  lime 
salts,  becoming  the  solid  framework  for  the  new  bone,  and 
eventually  becoming  bone.  Other  reparative  cells  are  also 
deposited  to  repair  the  injured  soft  tissues. 


392  FEACTURE    IN    GENERAL 

Treatment. —  General  treatment  includes  measures  for 
tlie  comfort  of  the  patient,  remedies  for  the  shock,  and  the 
control  of  the  hemorrhage  when  it  is  present.  Antiseptic 
precautions  must  be  taken.  The  parts  should  be  placed 
in  as  near  the  normal  position  as  possible,  which  is  usually 
the  most  comfortable  position.  A  temporary  splint,  sup- 
port or  bandage  should  be  adjusted.  Permanent  dressings 
should  be  applied  as  soon  as  possible,  as  swelling,  extrav- 
asation, hemorrhage,  and  injury  to  the  soft  parts  by  the 
ends  of  the  bones  remaining  in  false  positions,  all  tend  to 
permanent  complications. 

The  cardinal  points  in  treatment  are  reduction  and 
retention.  The  injury  produces  some  insensibility  and 
early  reduction  is  less  painful.  It  is  also  easier,  as  the 
muscles  are  temporarily  relaxed.  This  is  best  accomplished 
by  grasping  the  extremity,  making  firm,  gentle  and  con- 
tinuous traction  with  one  hand,  and  with  the  other  hand 
forcing  the  bones  into  position,  placing  them  as  near  the 
normal  position  as  possible.  An  anesthetic  may  be  neces- 
sary if  there  is  great  displacement  or  marked  muscular 
contraction,  or  if  there  has  been  much  delay,  with  conse- 
quent swelling,  etc.,  or  when  the  pain  is  very  great.  An 
anesthetic  should  always  be  used  if  the  reduction  is  ques- 
tionable or  not  satisfactory.  Eetention  of  the  fragments 
in  the  reduced  position  is  usually  accomplished  by  using 
coaptation  splints,  sandbags,  or  plaster  of  Paris,  along 
with  extension  and  counter-extension.  The  best  results  are 
obtained  by  splints  of  boards,  perforated  metal,  wire  gauze, 
felt,  sandbags,  etc.,  held  in  position  with  a  roller  or  other 
bandage.  Plaster  of  Paris  is  the  most  universally  used 
permanent  splint.  When  reduction  cannot  be  accomplished 
after  a  few  days,  some  advise  immediate  wiring. 


CHAPTEE  XXXV 


FEACTUEE    OF    THE    MANDIBLE 


Owing  to  its  prominence,  as  well  as  to  the  fact  that  it  is 
composed  of  a  semicircle  supported  at  points  remote  from 
where  violence  is  received,  this  bone  is  subjected  to  quite 
frequent  fracture.  It  exhibits,  however,  considerable  elas- 
ticity throughout  the  arch  from  one  condyle  to  the  other, 
and  for  this  reason  may  be  subjected  to  considerable  vio- 
lence, especially  in  young  subjects,  without  fracture. 

Frequency.— Fractures  of  the  mandible  occur  as  fre- 
quently as  fractures  of  all  other  bones  of  the  face  com- 
bined. They  may  be  of  any  of  the  varieties  enumerated 
under  the  general  head  of  fracture,  but  are  most  frequently 
compound  when  the  fracture  is  through  the  horizontal  por- 
tion, since  a  force  sufficient  to  produce  a  fracture  of  this 
bone  will  generally  tear  through  the  periosteum  and  mu- 
cous membrane  surrounding  it.  Simple  fractures  may  be 
expected  when  the  break  is  through  the  angle  or  ramus. 
Five  per  cent,  of  fractures  are  at  two  or  more  places,  or 
multiple,  and  many  of  them  are  comminuted. 

Location.— The  most  frequent  points  of  fracture  are 
about  as  follows,  a  slight  variation  depending  upon  the 
variety  and  direction  of  the  violence :  First,  mental  fora- 
men; second,  second  molar;  third,  symphysis;  fourth,  ra- 
mus ;  and  fifth,  neck  of  condyle. 

Causes.— The  causes  that  produce  fractures  are  fist 
blows  and  other  crushing  forces  imparted  directly  against 
the  bone,  as  when  the  head  is  caught  under  a  wheel  or  in 
falling  from  a  height,  as  from  a  bicycle. 

393 


394  FRACTURE    OF    THE  MANDIBLE 

Symptoms.— The  symptoms  are  deformity,  pain,  crepita- 
tion, and  mobility.  Abrasion  of  the  skin  and  swelling  with 
disability  or  inability  to  use  the  mandible  may  also  be 
present. 

The  amount  of  displacement  and  resultant  deformity 
depends  greatly  upon  the  variety  of  fracture.  Transverse 
fractures  through  the  symphysis  and  at  other  points,  un- 
less produced  by  great  violence,  are  generally  in  very  fair 
position  and  are  retained  so  with  little  difficulty.  In  ob- 
lique fractures  at  any  point  displacement  occurs,  but  it  is 
most  marked  when  the  fracture  is  through  the  body  of  the 
mandible.  Oblique  fractures  are  most  difficult  of  reduc- 
tion, and,  when  reduced,  remain  so  only  until  the  patient 
has  had  an  opportunity  to  place  the  muscles  in  contraction 
after  an  anesthetic.  The  deformity  is  then  as  bad  as  before 
reduction.  Probably  the  most  difficult  variety  of  fracture 
to  reduce  and  retain  in  position  is  one  beginning  at  the 
mental  foramen  and  extending  backward  and  inward 
through  the  first  molar.  It  can  be  readily  observed  that 
the  geniohyoid  and  geniohyoglossus,  with  their  attach- 
ments to  the  genial  tubercles,  pass  directly  backward,  and 
every  movement  of  the  tongue  tends  to  draw  the  symphysis 
backward.  In  opposition  to  this,  the  masseter  and  tem- 
poral muscles  have  a  tendency  to  draw  the  angle  and  re- 
maining portion  of  the  body  upward.  With  two  such  forces 
as  these  working  in  opposite  directions,  it  can  readily  be 
seen  that  mechanical  means  are  necessary  to  overcome 
them  so  as  to  readjust  the  fragments. 

Diagnosis.— Diagnosis  is  not  difficult,  and  is  based  upon 
a  consideration  of  the  symptoms  already  enumerated.  In 
fractures  through  the  ramus,  neck  of  the  condyle,  and  coro- 
noid  process,  it  is  sometimes  very  difficult  to  make  out  the 
existence  of  the  discontinuity. 

Complications.— Complications  which  are  likely  to  be 
present  are  excessive  hemorrhage,  rupture  of  the  dental 
artery,  and  infection,  which  frequently  follows  compound 


TREATMENT   OF  FRACTUEE  395 

fracture,  since  it  is  difficult  to  treat  the  wound  antiseptic- 
ally,  in  which  case  more  or  less  necrosis  of  the  process 
results. 

Repair.— Repair  generally  follows  if  adjustment  has 
been  made  early  and  the  wound  is  kept  fairly  clean.  Liquid 
food  can  always  be  taken  into  the  mouth  through  the  teeth, 
or  it  may  be  introduced  through  a  curved  tube  or  catheter, 
back  of  the  molars.  The  patient  should  be  taught  from  the 
start  to  hold  the  teeth  firmly  together. 

Treatment.— Treatment  may  be  briefly  summarized  as 
follows : 

First.  AsejDtic  measures  only. 

Second.  Wire  splints  about  the  teeth. 

Third.  Angle's  method. 

Fourth.  Bone  wiring. 

Fifth.  Interdental  splints. 

Sixth.  External  bandages  and  appliances. 

Aseptic  Measures  Only. — When  no  displacement  exists, 
no  mechanical  treatment  is  required.  Care  should  be  taken 
to  keep  the  parts  in  an  aseptic  condition  to  prevent  infec- 
tion. 

Wire  Splints. — When  slight  displacement  exists,  the 
parts  may  be  held  together  by  wire  splints  extending  about 
several  or  all  of  the  teeth.  Hammond  throws  a  wire  about 
all  of  the  teeth,  including  the  molars  on  both  sides,  passing 
along  the  lingual  as  well  as  the  buccal  surfaces  of  the  teeth. 
Additional  wires  of  much  smaller  gauge  are  thrown  about 
and  between  the  teeth  on  either  side  of  the  fracture.  This 
method  is  not  satisfactory  when  there  is  much  tendency 
to  re-displacement.  In  almost  all  fractures  one  or  more 
teeth  are  loosened,  and  when  an  effort  is  made  to  hold  the 
fragments  in  position  by  the  use  of  wire,  it  should  be  car- 
ried far  enough  away  from  the  line  of  fracture  to  guaran- 
tee firm  teeth.  Kingsley  and  Weston  have  devised  a  retain- 
ing splint  by   swaging  silver  or  other  metal  over   a  die 


396 


FKACTURE    OF    THE  MANDIBLE 


whicli  corresponds  with  the  remaining  projection  from  the 
mandible.  This  method  is  satisfactory  when  there  is  little 
tendency  to  displacement.     (Figure  197.) 

Angle's  Method. — More  recently  it  has  been  the  prac- 
tice to  secure  a  better  juxtaposition  of  the  parts  by  the  use 


Fig.  197. — Dental  Splint  Swaged  to  Fit  the  Teeth  and  Cemented  Into 

Position. 

of  bands  and  screws  thrown  about  the  teeth,  devised  by 
Angle.  He  has  introduced  a  method  of  securing  fragments 
which  is  very  satisfactory  in  many  instances.    The  essential 

step  of  this  method  is  to  secure  an 
anchorage  from  the  solid  teeth  with 
metallic  bands  thrown  about  them 
and  firmly  held  by  screws.  Angle 
has  several  methods  in  making  trac- 
tion from  one  band  to  another.  If 
the  fracture  is  single  and  transverse  without  much  displace- 
ment, the  fragments  are  held  by  a  rod  which  passes  from 
one  band  to  another  and  which  is  tightened  by  a  screw. 
By  this  means  the  fragTQents  can  be  drawn  toward  each 
other  with  considerable  force.  He  also  uses  buttons  instead 
of  the  rod,  projecting  from  the  band  on  both  sides  of  the 
fracture,  which  are  drawn  together  by  the  use  of  wire.    If 


Fig.  198. — Angle's  Bands. 


BONE   WIRING  397 

it  is  impossible  to  secure  proper  acljiistment  from  the  teeth 
of  the  mandible,  or  in  cases  where  there  is  more  than  one 
fracture,  he  suggests  that  bands  may  be  placed  about  the 
teeth  in  the  maxilla,  and  wires  carried  up  to  them,  thus 
holding  the  fragments  of  the  £:.::, 
broken  mandible  against  the      ^^^M'  y 

teeth  of  the  maxilla.  ^^^^"t.^_   .k^  -  -  i-f 

Bone      Wiring. — In      all     ^I^SiJ^'^P"^  i-- 

cases    of    fracture    of    the        ^^^^^^^5*''53^W^  - ^- 
mandible,  as  well  as  of  other       ^^^^^^^^^^s?^    ^^ 
bones  throughout  the  skele-      ^^^^^"P^"^  Py " 

ton,  where  there  is  the  least      ^^^^^^fc^^,  ^___;^^'  ^ 
tendency    to     displacement,     t-     ^^n     u  v  at.^t 

•^  /  '      Fig.  199. — Holding  1  racttjked  Man- 

nothing    serves,    in    the    au-  dible     to    Maxilla    with    Wire 

,  T        ,  •    •  1  1  Around  Pins  on  the  Band. 

thor's  opinion,  such  an  ad- 
mirable purpose  as  bone  wiring.  In  this  method  there  is 
a  certainty  that  the  bones  can  be  readjusted  and  sufficient 
traction  placed  upon  the  fragments  to  hold  them  in  apposi- 
tion until  repair  has  taken  place,  and  this  is  the  treatment 
which  should  take  the  place  of  all  other  methods  in  fracture 
of  the  mandible  with  displacement.  The  operation  is  not 
difficult  and,  when  properly  done,  requires  no  after  atten- 
tion, the  patient  being  permitted  to  open  and  close  the 
mouth  with  almost  as  much  freedom  as  though  fracture 
did  not  exist. 

The  method  consists  in  drilling  a  hole  through  the  man- 
dible from  the  external  surface  of  the  bone  into  the  sub- 
lingual cavity.  The  drill  hole  should  be  made  between  the 
apices  of  the  second  and  third  teeth  from  the  lines  of  frac- 
ture, when  this  is  possible,  so  as  to  guarantee  firm  anchor- 
age for  the  wires.  The  wire  is  passed  from  without 
through  the  bone  to  the  lingual  surface  and  with  a  notched 
or  perforated  drill  it  is  drawn  out  through  the  second  drill 
hole.  The  two  ends  of  the  wire  are  now  drawn  out 
firmly,  and  the  loop  on  the  inside  of  the  bone  is 
molded   to  the    surface   of   the  mucous   membrane.      The 


398 


FRACTURE    OF   THE  MANDIBLE 


free  ends  are  twisted  so  as  to  bring  the  ends  of  the 
bones  into  perfect  apposition.  The  wire  is  now  turned  up 
along  the  remaining  teeth,  so  that  the  sharp  end  may  not 
irritate  the  mucous  membrane  of  the  Up.  Wlien  one  side 
has  a  tendency  to  drop,  the  drill  holes  should  not  be  on  the 
same  plane;  but,  instead,  the  hole  in  the  high  fragment 
should  be  well  up  to  the  gingival  margin,  and  the  one  in 
the  lower  fragment  close  to  or  below  the  dental  canal.  In 
some  instances  it  will  require  but  one  hole,  the  teeth  being 


Fig.  200. — Holding  Fragments  in  Position  with  a  Screw  Rod  from  Bands. 

used  for  anchorage.  This  is  usually  the  case  in  fractures 
near  the  angle. 

Before  the  adjustment  of  the  fragments,  the  field  should 
be  thoroughly  cleansed  with  a  fifty-per-cent.  solution  of 
alcohol.  Iron  wire,  20-gauge,  is  always  used,  since  it  is 
tougher,  less  irritating,  and  in  every  way  superior  to  silver 
w^ire. 

The  wires  are  permitted  to  remain  in  position  for  about 
six  weeks,  or  longer  if  union  has  not  taken  place.  They 
cause  little  irritation  or  sloughing  of  the  gum  or  mucous 
membrane,  as  might  be  supposed ;  and,  if  necrosis  of  bone 
from  pressure  of  the  wire  ever  occurred  in  the  author's 
cases,  it  was  too  insignificant  to  attract  attention.  Band- 
ages and  swaddling-cloths  are  not  necessary.  The  patient 
soon  learns  to  hold  the  teeth  together.    The  mouth  should 


BONE    AVIRING 


899 


be  cleansed  with  some  strong  antiseptic  every  hour  or  so. 
If  infection  occurs,  an  ice-cap  should  be  applied  directly 
to  the  face.  Under  this  treatment  suppuration  seldom 
occurs. 

In  the  case  illustrated  in  figure  205  the  posterior  frag- 
ment was  tilted  up  by  the  masseter,  leaving  a  displacement 


Fig.  201. — Drilling  the  Bone  in  a  Fractured  Mandible. 


Fig.  202. — Notched  Drill  and  Wire.     Showing  method  of  attaching  thread. 

of  about  half  an  inch.  The  object  in  wiring  was  to  pull  the 
anterior  fragment  upward  against  the  posterior.  Since 
the  molar  was  perfectly  solid,  it  served  for  an  anchorage. 
The  drill  was  passed  through  between  the  roots  of  the  bi- 
cuspids. This  furnished  an  upward  and  backward  traction 
and  a  perfect  adjustment  w^as  not  difficult.  Union  followed, 
and  the  wire  was  removed  in  six  weeks,  with  perfect  articu- 
lation and  no  external  deformity. 


400  FRACTURE    OF   THE  MANDIBLE 

The  case  illustrated  in  figure  206  was  that  of  a  boy 
aged  seventeen,  whose  face  was  caught  by  the  drop-chute 
of  a  coal-tipple,  resulting  in  two  fractures  of  the  mandible, 
the  first  being  through  the  angle  on  the  left  side,  and  the 
second  passing  obliquely  across  from  without,  inward  and 
forward,  beginning  at  the  first  bicuspid  and  ending  at  the 
first  incisor  on  the  same  side.    This  case  was  not  seen  until 


Fig.  203. — Threading  Drill  Hole  with  Wire. 


Fig.  204. — Chisel  Used  to  Freshen  Ends  of  Bones  in  Old  Fractures. 

the  ninth  day,  after  the  ordinary  mechanical  methods  had 
been  used  without  success.  Since  the  fracture  was  quite 
oblique,  but  one  drill  hole  was  made  through  the  bone,  and 
the  wire  brought  up  over  the  alveolus  and  twisted  with  suf- 
ficient force  to  hold  the  fragments  in  position.  After  wir- 
ing the  anterior  fracture  by  the  usual  method,  there  was 
no  tendency  to  displacements  of  the  fragments  at  the  poste- 
rior fracture,  and  repair  took  place  with  but  slight  de- 
formity. 


INTERDENTAL   SPLINTS  401 

Figure  207  shows  a  fracture  through  the  ramus  above 
the  molar  teeth  on  the  right  side  as  the  result  of  a  direct 
blow  against  the  body  of  the  mandible  on  the  left  side.  The 
displacement  was  toward  the  right  and  downward.  To 
throw  the  teeth  in  articulation,  a  wire  was  secured  to  the 
first  molar  on  the  right  and  a  second  to  the  upper  central 
from  the  right.  After  throwing  the  mandible  around  into 
proper  position,  the  wires  were  twisted  together  and  held 


Fig.  205. — Fracture  Through  Molars,  Showing  Method  of  Making  Trac- 
tion TO  Overcome  a  Muscular  Spasm  and  Approximate  the  Bones. 

in  this  position  without  difficulty.  Eei3air  followed  with 
satisfactory  results. 

Figure  208  shows  a  fracture  through  the  symphysis  as 
a  result  of  a  blow  on  the  left  side  of  the  face.  There  was 
considerable  displacement,  and  the  dentist  and  physician 
were  unable  to  hold  the  fragments  in  position.  At  the  end 
of  two  weeks  the  bone  was  wired  by  the  through-and- 
through  method.  Four  weeks  later  the  wire  was  removed, 
satisfactory  union  having  taken  place  without  complica- 
tion. 

Interdental  Splints. — Interdental  splints  answer  very 
well  to  retain  the  fragments  in  position  in  some  cases.  In 
their  use. the  splint  rests  against  the  upper  teeth,  and  the 


402  FRACTURE    OF   THE  MANDIBLE 

fractured  mandible  is  held  up  against  the  under  surface 
of  the  splint  by  a  Barton  or  other  bandage.  This  necessi- 
tates making  a  fenestra  in  the  splint  through  which  food 
may  be  given  to  the  patient.  Theoretically,  interdental 
splints  appear  to  be  a  very  satisfactory  method  of  treat- 
ment, but  in  the  author's  hands  they  have  been  anything 
but  satisfactory,  since  it  is  difficult  to  keep  them  in  position, 
and,  if  there  is  a  tendency  to  displacement  of  the  fragment, 
sufficient  force  to  hold  the  displacement  in  position  is  not 


Fig.  206. — ^Double  Fracture  Showing  Wires  in  Position. 

easily  obtained.  Any  mechanism  that  remains  in  the  mouth 
for  extended  periods  must  necessarily  be  unsanitary.  Es- 
pecially is  this  true  in  cases  of  fracture  where  open  wounds 
exist.  An  interdental  splint,  to  be  effective,  must  be  con- 
tinuously worn  for  at  least  one  month,  usually  six  weeks. 
While  an  effort  is  made  daily  toward  cleansing,  putrefac- 
tive conditions  are  always  found.  Eemoval  of  the  splint 
would  mean  displacement. 

External  Appliances. — The  treatment  of  fractures  of 
the  mandible  has  included  almost  every  variety  of  mechan- 
ical apparatus  that  could  possibly  have  been  used  for  the 


AFTER-TREATMENT 


403 


purpose.  The  bandage  of  Barton,  or  of  Hamilton,  or  Gar- 
retson's  modification  of  Barton's,  or  the  vulcanite  splint 
adjusted  to  the  external  surface  of  the  mandible,  as  ad- 
vised by  Heath,  or  the  same  variety  of  external  support 
made  of  metal,  plaster  of  Paris  or  other  material,  are  all 
methods  of  a  more  or  less  temporary  nature,  and  are  effi- 
cient only  in  those  cases  where  the  fracture  is  transverse 
and  the  displacement  is  not  oreat,  or  when  reduction  has 


Fig.  207. — Fracture  of  Ramus  with  Wires  in  Position. 

been  accomplished  and  there  is  no  tendency  for  displace- 
ment to  return.  With  these  methods  it  is  impossible  to  hold 
oblique  fractures  of  the  ramus,  or  any  part  of  the  bone 
which  includes  the  teeth,  in  perfect  position.  Previous  to 
the  introduction  of  interdental  splints  and  wiring,  it  was 
quite  common  for  considerable  deformity  to  follow  frac- 
tures of  the  mandible. 

After-Treatment. — In  the  after-treatment  of  fracture  of 
the  mandible,  if  the  retaining  apparatus  has  secured  and 
maintained  a  perfect  adjustment  throughout,  it  should  be 


404 


FRACTURE    OF    THE  MANDIBLE 


kept  in  position  for  six  or  eight  weeks  in  the  most  favora- 
ble cases.  In  compound  fractures  with  suppuration,  which 
is  usual,  a  much  longer  time  is  required  for  perfect  union 
to  take  place.  If  mechanical  means  are  perfect,  external 
bandages  and  apparatus  are  entirely  unnecessary. 

Fractures  of  the  Alveolar  Process.— Not  an  infrequent 
condition  is  a  fracture  through  the  alveolar  process,  the 
line  of  break  extending  along  the  roots  of  teeth  and  parallel 


^  Fig.  208. — Fracture  of  Symphysis  with  Wires  in  Position. 

with  the  line  of  the  teeth,  splitting  off  one  side  of  the  proc- 
ess. The  most  frequent  fracture  of  the  alveolar  process 
results  from  extraction  of  teeth.  Such  fractures,  in  rare 
instances,  may  be  the  result  of  unskilful  extractions,  but  in 
the  majority  of  cases  are  the  result  of  unusually  curved 
roots,  or  ankylosis  between  the  tooth  and  process,  following 
old  inflammation.  As  a  rule,  no  treatment  is  necessary, 
since  the  surface  granulates  and  the  parts  are  restored  to  a 
normal  condition,  the  amount  of  deformity  depending  en- 


AFTER-TREATMENT 


405 


Fig.  210. 
Figs.  209  and  210. — Longitudinal  Fracture  of  the  Alveolar  Process,  In- 
cluding Four  Teeth,  as  a  Result  of  a  Kick  by  a  Horse.  Treatment  in- 
cluded replacement  of  the  fragment  which  was  held  in  position  by  the  use 
of  wires  extending  back  to  the  molars  on  both  sides,  which  were  held  in  posi- 
tion by  finer  wires  passing  from  the  internal  to  the  external  bar  between 
the  teeth. 


406  FRACTURE    OF    THE    MANDIBLE 

tirely  on  the  size  of  the  fragment  removed.  If  it  includes 
several  teeth  down  to  the  apex,  it  may  be  necessary  to  make 
an  interdental  splint-bridge  to  remedy  the  defects,  and  make 
perfect  the  masticating  powers. 

The  method  of  feeding  these  patients  is  always  a  ques- 
tion of  some  concern.  In  cases  where  no  teeth  have  been 
removed,  it  has  been  suggested  that  a  tooth  be  extracted 
before  adjustment  of  the  teeth ;  but  this  has  not  been  found 


Fig.  211. — Obstetric  Fracture  op  Mandible. 

necessary  in  a  single  instance.  The  method  used  has  been 
to  pass  a  soft  catheter  or  a  curved  glass  tube  back  of  the 
back  teeth  into  the  mouth ;  a  fountain  or  other  syringe  can 
be  used  to  force  liquids  into  the  oral  cavity.  In  many  cases 
the  patient  can  suck  the  liquid  from  a  glass  with  ease,  pro- 
vided the  tube  is  made  with  sufficient  curve  to  permit 
closure  of  the  lips. 

Case  of  Obstetric  Fracture.— In  figure  211  we  have  a 
case  of  obstetric  fracture  of  the  jaw  which  must  have  at 
the  same   time  injured  the  sympathetic  nervous  system, 


OBSTETRIC    FRACTURE  407 

since  there  is  not  only  atrophy  of  the  bone,  but  of  all  of  the 
soft  tissues  of  the  left  side  of  the  face,  including  the  lower 
half  of  the  ear,  and  apparently  all  that  part  of  the  tem- 
poral bone  which  forms  the  external  meatus. 

It  will  be  observed  that  the  entire  left  half  of  the  man- 
dible has  never  developed,  and  that  it  is  practically  a 
straight  line  from  the  temperomandibular  joint  to  near  the 
symphysis.  The  only  operation  that  could  be  done  in  this 
case  would  be  to  fracture  the  bone  near  the  median  line  and 
make  a  second  fracture  at  the  angle.  After  this  is  done, 
the  bone  is  to  be  held  out  either  by  a  bridge  work,  which 
extends  across  the  tongue  within  the  oral  cavity,  or  an 
external  bridge  work  extending  from  the  side  of  the  head 
to  the  joint,  the  bone  being  wired  up  to  it. 

The  operation  has  not  been  done  for  the  reason  that  the 
boy  has  recently  had  scarlatina,  which  has  left  nephritis. 


CHAPTEE  XXXVI 

FEACTUEE   OF    MAXILLA   AXD    UPPEE    PAET    OF   FACE 

FRACTURE  OF  THE  MAXILLA 

Fractures  of  the  maxilla  are  most  frequently  of  the  nasal 
process  as  a  comiolication  of  nasal  fractures,  or  of  the  al- 
veolar process  as  a  result  of  extraction  or  blows  re- 
ceived upon  the  teeth,  the  force  carrying  along  with  the 
teeth  a  considerable  portion  of  bone  back  of  them.  Such 
fractures  are  usually  of  the  incisors  or  cuspid  teeth,  but 
may  include  the  bicuspids  or  molars,  when  a  not  infrequent 
complication  is  perforation  of  the  antral  floor. 

These  fractures  are  generally  compound,  and  are  the 
result  of  direct  violence.  The  line  of  fracture  may  include 
the  antrum,  when  the  palate  bone  is  also  included.  Suffi- 
cient force  may  crush  in  the  malar  bone  so  as  to  fracture 
the  anterior  wall  of  the  antrum.  Force  applied  to  the  al- 
veolus across  the  upper  lip  may  break  the  entire  roof  of  the 
mouth  from  the  skull.  Either  the  right  or  left  maxilla  may 
be  torn  from  the  face,  the  line  of  fracture  being  through 
the  antrum  into  the  nasal  cavity  and  out  through  the  roof 
of  the  mouth. 

Symptoms.— Hemorrhage  from  the  nose,  mouth,  or 
pharynx  is  quite  common  and  may  require  ligation  of  the 
external  carotid.  Crepitation,  mobility  and  emphysema 
are  usually  present,  and,  with  hemorrhage  and  the  history, 
constitute  the  principal  diagnostic  evidence.  Patients  bear 
these  injuries  well,  as  well  as  all  injuries  about  the  face, 
and  complete  union  generally  takes  place,  though  deform- 

408 


FRACTURE    OF    THE    MAXILLA 


409 


ity  is  not  always  controlled,  since,  owing  to  tlie  usually  ex- 
tensive swelling  with  emphysema,  it  is  not  always  possible 
to  effect  a  perfect  adjustment  of  the  displaced  bones. 

Treatment. — Treatment  consists  in  reduction  of  fracture 
and  retention  of  the  fragments  by  wire  or  mechanical 
means  for  six  or  eight  weeks. 

Figure  212  rej^resents  the  apparatus  used  in  a  fracture 
of  both  maxillse  through  the  nasal  and  antral  cavities  with 
separation  of  the  two  bones  in 
the  median  line.  The  apparatus 
is  that  devised  by  Kingsley 
many  years  ago  and  is  un- 
doubtedly the  best  for  treating 
these  cases.  The  apparatus 
was  removed  every  two  or 
three  days  and  boiled  so  as  to 
keep  it  in  a  sterile  condition. 
The  accident  was  the  result  of 
the  kick  of  a  horse,  breaking 
the  nose  as  well  as  causing  sev- 
eral lacerations  of  the  face. 
Extensive  ecchymosis  of  the 
left  conjunctiva  occurred.   The 

use    of    the    splint    was    perma-     F^«-  212.-Fracture  of  Maxilla, 
^  ^  SHOWING  Apparatus. 

nently     discontinued     on     the 

twenty-second  day  after  the  accident,  sufficient  union  hav- 
ing taken  place. 

A.  L.  C.  (see  figure  213),  while  looking  down  a  freight 
elevator  shaft,  with  face  over  a  gate,  was  struck -by  the 
elevator  upon  the  top  of  the  head  between  the  parietal 
eminences.  The  line  of  force  was  from  this  point  to  the  tip 
of  the  nose.  The  upper  edge  of  the  gate  struck  the  bridge 
of  the  nose,  crushing  it  down  and  tearing  the  cartilage 
loose.  The  line  of  fracture  extended  through  the  antra 
back  from  the  anterior  nares  through  the  posterior  nares, 
and  included  both  the  pterygoid  processes  of  the  sphenoid. 


410 


FRACTURE  OF  UPPER  PART  OF  FACE 


The  roof  of  the  mouth  could  be  freely  moved,  and  the  frag- 
ment carried  along  with  it  the  hamular  process  of  the  in- 
ternal pterygoid  plate,  as  well  as  the  external  plate.  At 
the  time  of  the  injury  the  external  maxillary  artery,  or  a 
considerable  branch  of  it,  was  torn  off,  resulting  in  such 
excessive  hemorrhage  as  to  produce  syncope,  one  of  the 
natural  hemostatics  which  served  well  in  this  case.    A  sa- 


FiG.  213. — Fracture  of  Maxilla,  Showing  Skull  Apparatus, 
Method  of  Applying  Bandage,  and  Result. 

line  of  one  quart  was  injected  into  the  median  cephalic  at 
the  elbow,  and  when  the  patient  aroused  hemorrhage  had 
ceased.  The  only  inconvenience  resulting  from  the  acci- 
dent has  been  occasional  neuralgic  pain,  confined  to  the 
maxillary  division  of  the  fifth  nerve. 

All  appliances  are  made  of  metal  to  fit  the  roof  of  the 
mouth  and  the  teeth.  Arms  are  soldered  to  the  sides  of 
the  plate  and  project  from  the  mouth  through  the  angles. 
The  plate  is  held  firmly  with  a  bandage  passing  over  the 
head.      (See  figures  212,  213,  214.) 


FRACTURE    OF    THE    MAXILLA 


411 


Maxillary  Fracture  From  Extractions.— During  extrac- 
tion of  teeth  it  is  quite  common  for  small  portions  of  bone 
to  come  away  with  a  tooth,  but  for  no  ill  results  to  be  an- 
ticipated. If,  however,  any  considerable  portion  of  bone 
is  attached  to  the  tooth  or  detached  from  the  process  by 
the  tooth  or  forceps,  careful  examination  of  the  parts 
should  be  made  by  the  operator,  so  as  to  guard  against  com- 
plications. 


Fig.  214. — Fracture  of  Maxilla  and  Mandible. 

It  is  an  occasional  complication  for  the  mandible  to  be 
broken  through  and  a  more  frequent  occurrence  for  the 
outer  or  inner  half  of  the  process  to  be  split  away  down 
to  the  apices  of  one  or  more  teeth.  In  the  maxilla,  es- 
pecially in  the  intermaxillary  process  where  the  bone  is  not 
so  stable,  the  entire  process  is  occasionally  torn  away.  This 
is  more  liable  in  mouths  that  have  had  suppurative  condi- 
tions about  the  teeth,  for  in  such  cases  ankylosis  of  the 
tooth  to  the  bone  usually  follows  if  the  pathological  change 


412 


FRACTURE  OF  UPPER  PART  OF  FACE 


has  extended  down  in  the  socket  for  any  distance.     (Figure 
216.) 

A  dentist  recently  came  to  the  author  and  showed  a 
molar  to   which  was  attached  the  process,  including  the 


Mt    . 

■Pt  i 

i^'Mjff^gg 

Kr'''f 

^HHa 

K'-' 

^«1 

i*A.  '  "',     '^B 

^9 

w*. 

u 

n 

r 

Fig.  215. 


Fig.  216. 


Fig.  217. 


Fig.  218. 


Figs.  215-218. — Four  Cases  in  Which  Portions  of  the  Maxilla  Were 
Broken  Away  in  an  Effort  to  Extract  a  Tooth.  In  three,  the  bony 
floor  of  the  antrum  was  removed.  The  membranous  floor  remained  intact 
and  antral  suppuration  did  not  follow. 


floor  of  the  antrum.  He  was  very  much  worried  and 
wanted  to  know  what  he  should  do.  He  was  advised  to  be 
sure  that  the  lacerated  gum  and  soft  tissues  were  adjusted 
across  the  cavity  left  by  the  removed  bone.  This  was  done 
and  repair  followed,  and  the  patient  never  knew  that  so 
much  bone  had  been  removed.     (Figure  215.) 


FRACTURE  OF  THE  MALAR  BONE      415 

draw  the  nose  into  line,  when  other  methods  fail.  For  the 
correction  of  old  deformities  following  fracture  of  these 
bones,  see  the  chapter  on  Facial  Deformities. 

FRACTURE   OF  THE  MALAR  BONE 

Fracture  of  the  malar  bone  is  generally  in  the  form  of  a 
depression  and  is  the  result  of  great  force  applied  directly 


Fig.  220. — Depressed  Fracture  of  the  Malar  Bone,  After  Operation. 
A  half-inch  incision  was  made  down  to  the  bone  between  the  two  branches  of 
the  transverse  facial  artery,  and  no  vessels  requiring  ligation  were  severed. 
The  l)one  was  drilled  and  the  coat  hook  screwed  into  it.  Since  this  was  a 
delayed  case  some  effort  was  required  to  effect  an  adjustment,  but  this  was 
satisfactorily  done. 

to  the  bone.  It  usually  involves  the  orbital  cavity  and  the 
antrum.  If  this  bone  is  depressed  greatly,  it  leaves  a  very 
disagreeable  deformity,  and  should  be  reduced  by  all 
means.  When  the  antrum  is  included,  disease  of  this  cavity 
does  not  necessarily  follow,  unless  the  fracture  is  made 
compound  by  a  rent  through  the  mucous  membrane.  Ee- 
duction  is  best  accomplished  by  cutting  down  upon  the 
bone  and,  if  it  cannot  be  returned  to  the  normal  position  l)y 


416     FRACTURE  OF  UPPER  PART  OF  FACE 

the  use  of  elevators,  a  coat  hook,  gimlet  or  other  screw  may 
be  bored  into  the  bone  deeply  enough  to  take  a  firm  grasp, 
when  sufficient  traction  may  be  made  to  lift  it  from  its  false 
position.  In  delayed  cases  it  may  be  necessary  to  make  the 
skin  incision  to  include  the  margin  of  the  bone,  so  as  to 
permit  the  use  of  an  elevator  under  the  edge,  when,  by  pry- 
ing, the  bone  can  usually  be  lifted  from  its  impacted  posi- 
tion. When  once  returned  to  place,  it  usually  remains  so 
until  repair  is  accomplished. 

Some  surgeons  have  used  screws  for  this  purpose,  but 
a  strong  forceps  or  pliers  is  necessary  to  secure  proper  ad- 


FiG.  221. — Coat  Hook  for  Elevating  Depressed  Fractures  of  the  Malar 

AND  Other  Bones. 

justment.  With  the  coat  hook  can  be  accurately  deter- 
mined just  how  much  force  is  being  made,  and  the  surgeon 
has  perfect  control  of  the  fragment. 

In  operating,  care  must  be  taken  to  avoid  the  temporo- 
malar  canal  on  the  external  surface  of  the  bone.  There  is 
also  danger  of  wounding  the  alveolar  branch  of  the  internal 


FRACTURE   OF   THE   ZYGOMATIC   ARCH  417 

maxillary  artery  with  the  drill  point  as  it  passes  through 
the  bone,  since  this  artery  passes  forward  and  downward 
between  the  malar  and  maxillary  bones. 

FRACTURE  OF  THE  ZYGOMATIC  ARCH 

Fracture  of  the  zygomatic  arch  is  quite  rare,  and  is  usu- 
ally the  result  of  direct  violence.  It  is  of  special  interest  to 
the  dentist  because  the  masseter  muscle,  which  is  inserted 
into  the  mandible,  has  its  origin  from  this  arch,  and  when 
this  is  fractured  the  movements  of  the  mandible  are  re- 
stricted, if  not  entirely  prevented. 

Symptoms. — The  symptoms  are  swelling  and  contusion, 
with  local  tenderness,  which,  when  marked,  prevent  a 
thorough  examination  when  the  arch  is  depressed.  The  de- 
pressed bone  may  press  upon  the  temporal  muscle  and 
contribute  toward  restriction  of  the  movements  of  the 
mandible. 

Treatment. — Treatment  consists  in  immobilizing  the 
mandible  by  a  Barton  bandage  until  repair  takes  place. 
When  the  arch  is  depressed  it  may  be  necessary  to  cut  the 
skin  down,  and,  with  a  hook  or  silver  wire  passed  under- 
neath, to  draw  the  bones  into  place.  When  once  replaced, 
there  is  little  tendency  to  redisplacement. 


CHAPTER  XXXVII 


DISLOCATIONS 


DISLOCATIONS  IN  GENERAL 


Dislocation  is  tlie  displacement  of  one  bone  from  an- 
other at  its  place  of  normal  articulation. 

The  varieties  are  as  follows:  partial,  when  there  is  a 
displacement  with  some  portion  of  one  articular  surface  in 
contact  with  some  portion  of  the  other  involved  in  the  dis- 
location; complete,  when  there  is  an  entire  separation  of 
the  two  articular  surfaces ;  simple  or  closed,  when  the  skin 
is  not  torn;  compound  or  open,  when  the  joint  has  atmos- 
pheric communication;  complicated,  when  important  struc- 
tures are  injured ;  traum,atic,  dependent  upon  an  injury  or 
where  immediate  violence  causes  displacement;  pathologi- 
cal or  spontaneous,  when  the  result  of  destruction  of  a  por- 
tion of  the  joint,  and  muscular  contraction  or  other  force 
gradually  produces  the  displacement ;  primitive,  when  it  is 
the  first  displacement  of  a  given  joint;  liahitucd  or  consecu- 
tive, when  subsequent,  or  possibly  frequent,  dislocations 
occur  in  the  same  joint;  double,  when  the  same  joints  are 
displaced  on  the  two  sides;  bilateral,  when  both  ends  of  a 
bone,  such  as  the  mandible,  are  displaced  at  the  same  time ; 
toted,  when  both  ends  of  a  long  bone  are  displaced;  midti- 
ple,  when  two  or  more  joints  are  simultaneously  displaced; 
recent,  when  seen  immediately  after  the  accident;  ancient 
or  old,  when  observed  after  some  repair  about  the  joint  has 
taken  place ;  congenital,  when  occurring  in  utero,  as  a  result 
of  defective  development  of  some  structure  entering  into 

418 


DISLOCATIONS    IN    GENERAL  419 

the  formation  of  the  joint.  Dislocations  occurring  during 
parturition  are  usually  classed  as  traumatic,  yet  are  ulti- 
mately considered  congenital,  since  they  generally  go  un- 
recognized until  the  patient  begins  to  use  the  joint. 

Anatomy.  — Structures  which  enter  into  the  formation 
of  a  joint  are  bones,  cartilages,  ligaments  and  synovial 
membrane.  Structures  which  surround  the  joint,  which 
control  the  movements  and  which  are  atfected  by  injuries 
to  it  are  tendons,  muscles,  nerves,  blood  vessels,  fascia  and 
skin.  Any  one  or  more  of  these  structures  may  be  injured 
in  dislocations. 

Bones  are  held  together  by  muscular  contraction,  and 
in  some  joints  by  internal  ligaments,  as  in  the  knee ;  but  the 
capsule  and  external  ligaments  have  little  to  do  with  keeping 
the  articular  fibro-cartilages  in  contact.  Flail-joint,  found 
in  paralysis,  is  an  illustration  of  the  muscular  element  in 
holding  bones  together.  Atmospheric  pressure  is  an  ele- 
ment which  only  assists  in  holding  bones  in  contact.  The 
distal  portion  is  considered  the  dislocated  part. 

The  location  average  for  dislocations  is :  ninety-two  per 
cent,  in  the  upper  extremities,  fifty-four  per  cent,  in  the 
shoulder,  six  per  cent,  in  the  lower  extremities,  and  two 
per  cent,  in  the  vertebral  column. 

Etiology. — The  causes  of  dislocation  have  to  be  consid- 
ered under  two  heads,  predisposing  and  exciting. 

Predisposing  Caz«ses.— Ball-and-socket  joints  are  more 
liable  to  displacements  on  account  of  the  very  free  motion 
in  every  direction,  while  hinge  joints  are  better  protected 
by  dense  ligaments  and  are  not  so  frequently  dislocated. 
So  it  may  be  laid  down  as  a  rule  that  the  greater  freedom 
of  motion  there  is  in  a  joint,  the  greater  liability  there  will 
be  to  dislocation.  Some  joints  are  so  situated  as  to  be  much 
more  exposed  to  violence  than  others,  and  are,  therefore, 
more  frequently  dislocated.  Dislocations  generally  occur 
in  adidts  or  middle-aged  individuals,  being  rare  in  children 
(with  the  exception  of  those  of  the  elbow  joint),  and  in  old 


420  DISLOCATIONS 

people.  Males  are  mucli  more  liable  to  suffer  from  disloca- 
tions than  females  on  account  of  their  greater  exiDosure  to 
serious  injuries.  The  condition  of  the  structures  around  a 
joint  may  predispose  to  dislocation;  for  example,  if  they 
have  been  stretched  by  previous  injury  or  effusion. 

The  exciting  causes  are  twofold;  either  external  vio- 
lence or  muscular  action.  Violence  may  cause  dislocation 
in  two  ways,  either  directly,  from  a  blow  on  one  bone  en- 
tering into  the  formation  of  a  joint,  driving  it  directly 
away  from  the  other;  or  indirectly,  where  a  fall  or  blow 
on  one  part  of  the  bone  is  transmitted  to  its  extremity  and 
forces  it  away  from  the  articular  surface  with  which  it  is 
in  contact. 

Symptoms.— The  signs  by  which  a  dislocation  may  be 
recognized  are :  pain,  which  is  usually  of  a  severe  and  sick- 
ening character;  impaired  mobility,  so  that  the  patient  to  a 
great  extent  is  unable  to  perform  the  various  voluntary 
movements  of  the  joint;  change  in  the  shape  of  the  joint; 
alteration  in  the  relationship  of  the  bony  prominences  in  the 
neighborhood  of  the  joints  to  each  other;  displaced  bone, 
which  can  sometimes  be  felt  in  its  new  situation ;  an  altera- 
tion in  the  length  of  the  limb,  as  it  is  sometimes  lengthened 
and  sometimes  shortened,,  according  to  the  position  of  the 
head  of  the  bone ;  an  alteration  in  the  direction  of  the  long 
axis  of  the  bone. 

Diagnosis.— Dislocations  may  sometimes  be  mistaken 
for  fractures.  The  chief  points  of  distinction  are  impaired 
mobility,  the  absence  of  crepitus,  and  the  fact  that  when 
the  deformity  is  reduced  it  does  not,  as  a  rule,  recur, 
whereas,  in  fractures  the  displacement  recurs  as  soon  as 
the  extending  force  has  been  removed. 

Pathology.— Motion  in  joints  is  limited  by  tension  made 
upon  the  ligaments  and  joints,  as  in  extreme  positions.  The 
sac  is  on  tension  on  one  side  and  relaxed  on  the  other. 
Hinge  joints  permit  motion  in  but  two  directions,  and  when 
lateral  displacement  occurs  the  lateral  ligament  must  be  de- 


DISLOCATIONS    IN    GENERAL  421 

stroyed.  Ball-and-socket  joints  permit  range  of  motion  in 
every  direction  on  account  of  the  redundant  joint  sac  on 
all  sides,  permitting  displacements  with  less  force  than  oc- 
curs in  more  fixed  joints.  Force  which  dislocates  joints  is 
usually  sufficient  to  rupture  the  sac  and  ligaments.  Syno- 
via escapes  into  the  surrounding  tissues  when  the  sac  is 
rent.  Muscles  and  tendons  are  placed  in  extreme  tension 
or  dislocated  under  the  displaced  head  of  the  bone,  greatly 
interfering  with  reduction.  Repair  is  prompt  when  bones 
are  replaced  promptly  and  when  there  is  no  complication. 

Complications.— There  may  be  fracture,  or  sprain  frac- 
ture, which  means  that  a  portion  of  bone  is  carried  with  a 
ligament.  Joint  sac  laceration  may  be  extensive.  Com- 
pound dislocation  may  occur  with  associated  laceration  of 
skin  and  soft  parts  on  the  side  of  the  joint  injured.  Frac- 
ture or  epiphyseal  separation  is  a  frequent  complication, 
and  a  diagnosis  is  not  easy  when  swelling  is  present.  Blood 
vessels  may  be  injured,  resulting  in  a  corresponding  degree 
of  impairment  and  nutrition,  swelling,  or  even  gangrene. 
Nerves  are  occasionally  torn  or  injured,  resulting  in  pain 
or  paralysis  of  muscles,  and  when  the  sympathetic  is  in- 
jured vasomotor  paralysis  may  result.  Traumatic  syno- 
vitis varying  in  proportion  to  the  amount  of  injury  always 
occurs. 

Treatment.— Treatment  of  dislocation  is  divided  into 
reduction,  which  is  the  prime  aim;  retention  of  the  bones 
in  a  normal  position  until  repair  has  taken  place;  and 
operation.  Immediate  reduction  is  advisable  for  two  rea- 
sons: first,  because  the  muscles  are  relaxed,  especially  if 
the  patient  is  sick  or  faint ;  and,  second,  because  the  trauma 
results  in  some  anesthesia  of  the  parts,  and  reduction  is 
less  painful.  When  an  effort  at  reduction  is  not  made  for 
several  hours,  the  muscles  will  have  become  rigid,  and  an 
anesthetic  may  be  required.  Reduction  is  accomplished  in 
two  ways — by  manipidation  and  by  extension.  Manipula- 
tion should  always  be  tried  first.    The  aim  is  to  make  the 


422  DISLOCATIONS 

head  of  the  displaced  bone  retrace  the  course  it  made  when 
the  dislocation  occurred.  The  direction  of  the  force  caus- 
ing the  displacement  should  be  ascertained.  The  member 
should  now  be  placed  in  the  position  relaxing  the  most  mus- 
cles. The  head  of  the  bone  is  now  rotated  and  pushed 
toward  the  joint.  Eeduction  will  usually  follow  such  a  pro- 
cedure in  partial,  and  many  times  in  complete,  displace- 
ment. 

Extension  is  used  only  when  manipulation  fails.  This 
method  includes  forcible  traction  upon  the  dislocated  mem- 
ber, so  as  to  overcome  the  muscular  contraction,  then  lift- 
ing the  bone  back  into  place.  Manipulation  may  be  used 
along  with  extension. 

Operation  to  return  the  bone  by  opening  into  the  joint 
may  be  required.  When  reduction  cannot  be  accomplished 
by  the  above  methods,  this  should  be  done  without  hesita- 
tion. Old  dislocations  should  be  given  a  trial  at  reduction 
under  an  anesthetic  by  the  bloodless  method,  but  care 
should  be  taken  not  to  do  great  damage  to  the  soft  sur- 
rounding tissues.  Open  operation  is  much  more  scientific, 
for  the  wound  is  made  where  desired,  the  bones  can  usu- 
ally be  replaced  and  the  joint  closed,  and  repair  will  occur 
without  great  damage  to  any  tissues. 

DISLOCATION  OF  THE  MANDIBLE 

Simple  dislocations  of  this  bone  occur  in  two  forms : 
unilateral,  when  only  one  side  is  displaced,  and  bilateral, 
when  both  articulations  are  thrown  forward.  They  are 
most  frequent  in  women,  and  between  the  ages  of  twenty 
and  thirty,  being  rare  in  the  young  and  in  the  very  aged. 

Causes.  — Conditions  which  predispose  to  this  dislocation 
are  paralysis,  shallow  glenoid  fossa,  and  dental  irregulari- 
ties. The  exciting  causes  are  traumatism  applied  to  one 
side  of  the  chin,  or  downward,  forcing  the  mouth  open, 
objects  forced  into  the  mouth,  yawning,  laughing,  and  ma- 
nipulation about  the  mouth  as  in  the  extraction  of  teeth. 


DISLOCATION    OF    THE    MANDIBLE  423 

Anatomy  and  Mechanism.— In  forward  dislocations  the 
force  applied  is  sufficient  to  depress  the  jaw  so  as  to  over- 
come the  masseter  and  temporal  muscles,  throw  the  condyle 
on  the  eminentia  articularis  in  partial,  and  over  in  com- 
plete, luxations.  The  pterygoid  muscles  assist  in  the  dislo- 
cation, and  the  hypoglossus  and  digastric  hold  the  tips 
of  the  mandible  down,  while  the  masseter  and  internal 
pterygoid  hold  the  condyle  firmly  against  the  temporal 
bone  in  its  abnormal  position,  thus  locking  the  jaw.  The 
capsule  is  not  always  ruptured. 

Symptoms.— Symptoms  are  inability  to  close  the  mouth, 
with  the  mandible  in  a  fixed  condition,  and  the  condyles 
abnormally  forward.  In  unilateral  dislocation  the  chin  is 
thrown  around  to  one  side.  The  diagnosis  is  not  difficult 
when  the  foregoing  symptoms  have  been  considered.  Care 
must  be  taken  to  exclude  fracture  of  the  ramus  or  neck  of 
the  bone.  The  direction  of  the  displacement  is  almost  al- 
ways forward  and  may  be  partial  when  the  condyle  of  the 
mandible  rests  on  the  eminentia  articularis  and  complete 
when  it  is  thrown  anterior  to  this  process.  Backward  dis- 
locations are  very  rare  and  are  produced  by  a  blow  or  by 
falling  upon  the  chin. 

Treatment.— Treatment  is  immediate  reduction,  with 
four  weeks '  rest,  which  will  be  followed  by  complete  recov- 
ery. Cases  have  gone  unrecognized  for  weeks,  and  the 
teeth  gradually  approximate  each  other.  The  only  deform- 
ity noticeable  will  be  the  prominence  of  the  chin.  Eeduc- 
tion  has  been  done  as  late  as  ninety-five  days  after  the  acci- 
dent. 

If  for  any  reason,  such  as  ignorance  or  timidity  of  the 
attendant,  a  dislocation  remains  unreduced  for  any  length 
of  time,  say  from  six  to  eight  weeks  or  more,  reduction  by 
manipulation  is  very  difficult.  If  a  nearthrosis  or  forma- 
tion of  a  new  joint  has  occurred  and  the  member  is  fairly 
useful,  no  attempt  at  reduction  should  be  attempted. 

When,  for  special  reasons,  it  is  desirable  that  further 


424 


DISLOCATIONS 


effort  at  reduction  should  be  made,  the  rational  procedure 
is  to  open  the  joint  and,  where  possible,  scoop  out  the  old 
joint  cavity  and  replace  the  bone  in  its  normal  position. 
When  this  is  impossible,  resection  or  arthrotomy  may  be 
practiced  with  promise  of  a  fairly  useful  joint. 

Reduction  is  best  accomplished  by  standing  in  front  of 
the  patient,  who  is  sitting  on  a  chair,  placing  the  thumbs. 


Fig.  222. — Reducing  Dislocated  Mandible.  One  hand  shown;  both  should 
be  used  in  the  same  position  as  shown.  Bandage  placed  around  thumb  to 
prevent  injury  from  teeth  when  the  bone  slips  into  position. 

protected  by  gauze  or  a  napkin,  well  back  in  the  angles  of 
the  mouth  and  against  the  rami,  and,  with  the  fingers  rest- 
ing under  the  symphysis  and  body,  elevating  the  chin,  while 
with  the  thumb  the  condyle  is  slid  down  and  back  under 
the  eminentia  articularis  into  place.  In  bilateral  disloca- 
tions one  side  should  be  reduced  at  a  time.  The  joint  should 
be  kept  at  rest  by  the  use  of  a  Barton  bandage  for  two  or 
three  weeks,  except  during  meals,  and  great  care  should  be 
observed,  as  recurrence  is  quite  common. 


CHAPTER  XXXVIII 

X-RAY,  IN    ORAL    SURGERY  ^ 

Diagnosis  of  oral  lesions  is  so  difficult  that  the  assist- 
ance of  the  X-ray  is  desirable.  There  is  no  difficulty  in 
showing  the  lesions  by  this  method.  The  only  difficulty  lies 
in  the  interpretation. 

Its  scope  of  usefulness  may  be  summarized  as  follows : 

1.  Teeth. 

2.  Fracture. 

3.  Sarcoma  and  carcinoma. 

4.  Salivary  calculi. 

Abscesses  of  teeth  may  be  recognized  before  the  actual 
formation  of  pus  occurs,  by  a  slight  increase  in  density, 
usually  about  the  root  of  the  tooth.  When  pus  formation 
occurs,  this  density  markedly  increases.  Later,  after  the 
pus  has  been  either  evacuated  or  absorbed  and  necrosis 
begins,  the  density  of  the  abscess  is  replaced  by  a  rarelica- 
tion  of  the  bone,  and  the  root  of  the  tooth  usually  stands 
boldly  up  into  this  shadow.  Abscesses  about  the  roots  of 
the  lower  molars  frequently  burrow  downward  and  open 
externally.  Such  a  sinus  may  be  opened  and  the  bone  cu- 
retted, but,  following  this  procedure,  the  wound  refuses  to 
close  completely,  and  the  X-ray  shows  a  sinus  leading  up  to 
the  apex  of  one  or  more  molar  roots.  Extraction  of  a  tooth 
and  through-and-through  drainage  is  followed  by  cure. 

Impaction  of  teeth  is  beautifully  demonstrated  by  the 
X-ray,  and  the  subsequent  extraction  or  regulation  is  ren- 

*  George  C.  Johnston,  Pittsburg,  Pa. 
425 


426  X-RAY   IN    ORAL    SURGERY 

dered  much  easier.  Necrosis  of  the  jaw,  other  than  that 
arising  from  tooth  abscess,  is  easily  recognized  by  the  rare- 
fication  of  the  bone.  Bone  cyst  is  diagnosed  from  bone 
abscess  by  the  faihire  of  the  cystic  contents  to  cast  the 
dense  shadow  characteristic  of  pus. 

The  orthodontist  who  makes  routine  use  of  the  X-ray 
is  thereby  enabled  to  proceed  more  intelligently  and  with 
greater  certainty  of  satisfactory  results.  Unerupted,  mis- 
placed or  missing  teeth  are  localized  exactly,  and  their  rela- 
tions to  the  surrounding  teeth  accurately  known.  Great 
care  must  be  exercised  in  the  search  for  missing  unerupted 
teeth.  That  a  tooth  is  not  found  near  its  proper  loca- 
tion is  no  evidence  that  the  patient  does  not  possess  this 
tooth.  It  may  be  in  the  antrum  or  lying  transversely 
beneath  the  root  of  an  erupted  tooth  or  lying  in  the  proper 
position  to  erupt,  being  unable  to  do  so  because  of  a  second 
unerupted  tooth  lying  directly  above,  transversely  in  the 
bone. 

The  diagnosis  of  infection  of  the  antrum  with  pus  can 
be  made  with  great  accuracy  by  means  of  an  antero-poste- 
rior  view  of  the  bones  of  the  face,  the  plate  placed  against 
the  nose  and  teeth,  and  the  ray  directed  through  the  spinal 
column  beneath  the  base  of  the  skull,  in  a  line  parallel  with 
the  floor  of  the  nose  and  directly  in  the  median  line.  For 
the  diagnosis  of  ethmoidal  and  frontal  disease,  the  ray 
should  be  directed  from  behind  forward,  but  at  an  angle 
of  twenty-two  and  one-half  degrees  with  the  basal  plane  of 
the  skull,  which  plane  passes  through  the  glabella  and  the 
two  external  auditory  meati.  The  infected  sinuses,  or  those 
containing  edematous  mucous  membrane  or  pus  or  granula- 
tion tissue,  will  cast  a  much  darker  shadow  than  the  normal 
sinus  or  sinuses  filled  with  air. 

Malignant  disease  of  the  bones,  such  as  carcinoma  and 
sarcoma,  may  be  recognized  by  a  rarefication  of  bone  and 
distortion  of  the  outlines  and  a  density  other  than  that  of 
normal  bone.    Sarcomata  in  or  about  the  upper  jaw  usually 


X-RAY    IN    ORAL    SURGERY 


427 


force  various  bony  plates  from  their  correct  location,  pro- 
ducing marked  distortion  and  density. 

Fracture  of  the  lower  jaw  may  be  easily  recognized  if 
there  be  present  more  or  less  displacement  of  the  frag- 
ments ;  but  if  the  bone  be  merely  cracked,  a  hasty  examina- 


Fig.  223. — Epithelioma  About  the  Molar  Tooth.  Appearance  of  lower  jaw 
when  made  on  plate  at  correct  angle.  Teeth  as  far  forward  as  lateral  in- 
cisors may  be  shown  perfectly.  Half  of  jaw  next  to  tube  is  thrown  up  on 
shadows  of  molar  and  orbit  and  is  to  be  disregarded. 

tion  may  fail  to  reveal  the  fracture,  which  may  be  discov- 
ered only  when  the  path  of  the  ray  is  made  to  traverse  the 
path  of  the  fracture.  Usually,  however,  fractures  of  the 
jaw  are  accompanied  by  considerable  displacement  and  the 
diagnosis  is  easy.  Dislocation  of  the  lower  jaw  and 
ankylosis  are  not  easily  diagnosed  by  the  X-ray,  on  account 
of  the  difficulty  of  passing  the  ray  in  such  a  direction  that 
the  articulation  may  not  have  superimposed  upon  it  the 


428 


X-RAY   IN    ORAL    SURGERY 


shadows  of  the  dense  portions  of  the  base  of  the  skull. 
Foreign  bodies  in  or  about  the  mouth  are  best  located 
stereoscopically,  as  described  below. 

Salivary   calculi   are   usually   quite   opaque    to   X-ray. 
They  are  more  frequent  in  the  submaxillary  duct,  and  here 


Fig.  224.— X-Ray  Technic. 

the  shadow  of  the  calculus  is  usually  superimposed  upon 
the  shadow  of  the  lower  jaw,  and  hence  may  be  overlooked, 
unless  a  careful  scrutiny  of  the  plate  be  made. 

Technic— The  length  of  exposure  necessary  to  produce 
a  radiogram  varies  with  the  location.    Thus,  a  plate  which 


CORRECT  -A  NG  te  ~ 

FOR    INCISOR    WtTH 

LOW      RAl-ATIwe  ARCH. 


Fig.  225. — Proper  Method  of  Taking  X-Ray  of  Jaw. 

must  show  the  antrums  requires  a  considerable  length  of 
exposure,  usually  fifty  to  one  hundred  milliampere  seconds. 
A  film  of  the  incisor  teeth,  on  the  contrary,  requires  but 
twenty  to  thirty  milliampere  seconds.  Films  an  inch  and  a 
quarter  by  an  inch  and  a  half  are  about  as  large  as  can  be 
used  satisfactorily  within  the  mouth.     They  may  be  ob- 


X-RAY    IN    ORAL    SURGERY  429 

tained  ready  folded  from  the  Eastman  Company,  each 
packet  containing  two  films  face  to  face,  folded  in  light- 
proof  envelopes,  which  are  fairly  water-tight,  at  least  suf- 
ficiently so  to  permit  of  placing  them  in  the  mouth  long- 
enough  to  secure  an  exposure.  They  must  be  pressed 
closely  against  the  process  and  extend  high  enough  up  into 


Fig.  226. — Impaction  of  Lower  Left  First  Molar,  Considered  a  Most 
Rare  Variety  of  Impaction.  The  tooth  was  removed  with  great  difficulty. 
It  will  be  observed  that  the  lower  margin  of  the  body  of  the  mandible  is 
pushed  down  below  the  normal  line  on  account  of  the  encroachment  upon 
the  inferior  line  by  the  depth  of  the  tooth. 

the  upper  jaw  and  far  enough  down  in  the  lower  to  receive 
the  image  of  the  apex  of  the  roots.  In  the  upper  jaw,  ow- 
ing to  the  shape  of  the  arch,  a  film  usually  lies  at  an  angle 
of  from  thirty  to  sixty  degrees  from  the  median  plane  of 
the  tooth,  the  image  of  which  is  desired.  If  the  ray,  there- 
fore, be  passed  on  a  line  perpendicular  to  the  median  plane 
of  the  tooth,  the  image  of  the  tooth  will  be  much  elongated 
and  distorted.     If  the  ray,  on  the  other  hand,  be  passed 


430  X-RAY   IN    ORAL   SURGERY 

perpendicular  to  the  plane  of  the  film,  the  image  of  the 
tooth  will  be  foreshortened  and  again  distorted.  Experi- 
ence will  teach  a  compromise  angle,  which  in  nearly  every 
case  will  so  correct  the  distortion  as  to  do  away  with  the 


Fig.  227. — Salivary  Calculus  in  the  Duct  of  the  Submaxillary  Gland. 

elongation  and  foreshortening  and  produce  an  approxi- 
mately correct  image  on  the  film.  The  posterior  portions  of 
the  lower  jaw  are  best  obtained  upon  a  plate,  the  patient  ly- 
ing down  with  the  atfected  side  of  the  jaw  upon  the  plate 
placed  film  side  up  in  a  light-proof  envelope.  By  moving 
the  tube  toward  the  patient's  body,  the  ray  may  be  directed 
beneath  the  upper  half  of  the  jaw,  which  will  aiopear  upon 


X-RAY   IN    ORAL    SURGERY 


431 


the  plate  as  overlying  the  orbit  and  antrum  of  the  affected 
side,  and  a  clean  image  of  the  affected  side  will  be  cast  upon 


FiG.  228. — X-Ray  Picture  Representing  a  Cyst  of  the  Mandible  which 
Developed  in  About  Nine  Months  from  the  Date  of  the  First 
Appearance  of  Enlargement.  Four  months  ago  first  molar  was  extracted 
and  considerable  serum  was  discharged.  This  did  not,  however,  prevent 
the  enlargement  of  the  tumor  on  the  external  surface  of  the  bone.  Opera- 
tion consisted  in  the  extraction  of  the  second  molar,  removal  of  the  third 
molar,  and  removal  of  both  cuspids,  as  the  roots  had  been  carried  outward 
along  with  the  wall  of  the  cyst  and  the  crowns  inward  at  an  angle  of  45 
degrees  to  the  mandible.  The  teeth  were  removed  because  the  apices  were 
exposed  in  the  cavity.  The  soft  tissues  on  the  external  surfa'ie  of  the  cyst 
and  teeth  were  dissected  loose.  The  bony  cyst  wall  which  had  been  devel- 
oping was  also  removed.  The  entire  soft  tissues  on  the  external  surface 
were  removed  and  dropped  down  into  the  cavity  of  the  cyst  after  it  had 
been  curetted,  with  the  idea  of  adhesion  taking  place  between  the  two 
surfaces.  Packing  was  placed  on  top  of  the  membrane  thus  forced  into  the 
cavity.  Repair  followed  immediately  and  the  patient  left  the  hospital  on 
the  fourth  day  without  an  unfavorable  symptom.  It  will  be  observed  that 
the  mandible  is  neaily  destroyed  immediately  under  the  bicuspids,  and  this 
would  no  doubt  have  occurred  in  a  short  time. 


432  X-RAY   IN    ORAL    SURGERY 

the  plate,  free  from  the  shadows  of  the  other  half  of  the 
jaw. 

When  desired,  a  stereoscopic  pair  of  negatives  may  be 
obtained  by  anchoring  the  patient's  head  securely  against 
movement,  placing  the  head  upon  a  tunnel,  centering  the 
tube  so  as  to  pass  the  ray  in  the  direction  of  desired  in- 
spection, moving  the  tube  one  and  one-half  inches  to  the 
righu,  making  an  exposure,  removing  the  exposed  plate  and 
substituting  a  second  plate  in  the  exact  position  of  the  first, 
the  patient  meantime  refraining  absolutely  from  movement, 
then  shifting  the  tube  to  the  left  until  it  occupies  a  position 
two  and  one-half  inches  to  the  left  of  its  first  position,  and 
making  a  second  exposure  of  exactly  the  same  duration  as 
the  first.  The  resulting  pair  of  plates  should  then  be  devel- 
oped to  the  same  density  and  placed  in  a  Wheatstone  re- 
flecting stereoscope,  wherein,  upon  transillumination,  the 
right  eye  of  the  observer  sees  the  plate  made  in  the  first 
tube  position,  and  the  left  eye,  the  plate  made  in  the  sec- 
ond tube  position.  The  blending  of  the  images  produces  a 
correct  stereoscopic  elf  ect.  The  plates  upon  the  stereoscope 
should  be  so  placed  that  the  distance  from  the  observer's 
eye  to  the  plate  is  exactly  the  same  as  the  distance  from  the 
anode  of  the  tube  to  the  plate  during  the  exposure. 


APPENDIX 

QUESTIONS  IN  ORAL  SURGEEY 


PART  I 


CHAPTER  I 


1.  When  was  tlie  first  microorganism  demonstrated  and  in  what 

secretions? 

2.  What   was   the   variety   of  the  first   microorganism    demon- 

strated ? 

3.  Who    made     the    first    systematic    classification    of    micro- 

organisms '? 

4.  When  and  by  whom  were  the  first  bacteria  discovered  in  the 

blood? 

5.  Who  established  the  nature  of  splenic  fever  and  anthrax  and 

thus  defined  the  relationship  of  bacteria  to  disease? 

6.  Give  the  morphology  of  a  bacterium. 

7.  How  are  bacteria  reproduced? 

8.  Give  the  biology  of  a  bacterium. 

9.  What  is  a  saphrophyte? 

10.  What  is  a  parasite? 

11.  Define  the  difference  between  a  parasite  and  a  saphrophyte. 
12   What  are  the  products  of  bacteria  ? 

13.  What   are  the  substances  found   in   the   media   of  bacterial 

growth  ? 

14.  Define  proteins. 

15.  What  are  ferments? 

16.  AVhat  are  toxins? 

17  Define  the  two  divisions  of  toxins. 

18  What  are  meant  by  the  followmg  terms  as  applied  to  the 

products    of   bacteria:    pigments;    photogenesis ;    fluores- 
cence ;  odors  ;  gas  ? 
19.  What  are  the  effects  of  bacteria  upon  the  tissues? 

435 


436  APPENDIX 

20.  Define  the  local  effects  of  bacteria  upon  the  tissues. 

21.  In  what  general  war  do  the  products  of  bacteria  affect  the 

system  ? 

22.  What  is  the  difference  between  a  primary  and  a  secondary 

focus  of  disease?    Give  illustrations. 

23.  What  is  immunity? 

24.  "What  is  infection  ? 

25.  Name  some  of  the  infectious  diseases. 

26.  What  germs  produce  acute  infections? 

27.  A\Tiat  germs  produce  suppurative  diseases? 

28.  Define  the  difference   between   a  pyogenic   and  a  pathogenic 

germ. 

29.  Define  the  difference  in  the  course  of  diseases  due  to  strepto- 

coccic and  those  due  to  staphylococcic  infections. 

30.  Give  the  definition  of  inflammation. 

31.  Give  the  five  cardinal  symptoms  of  inflammation. 

32.  Give  the  causes  of  inflammation. 

33.  What  are  the  phenomena  of  inflammation? 

34.  Describe  the  vascular  change  in  inflammation. 

35.  What  is  meant  by  exudation  as  applied  to  inflammation? 

36.  Describe  the  process  of  proliferation  in  an  inflammatory  area. 

37.  What  is  degeneration  of  tissues  during  inflammation? 

38.  Name  the  six  varieties  of  inflammation. 

39.  What  is  hyperemia? 

40.  What  is  the  difference  between  active  and  passive  hyperemia 

or  congestion? 

41.  What  are  the  causes  of  congestion? 

42.  Give  six  results  of  inflammation,  briefly  deflning  each  change. 

43.  What  is  necrosis  as  applied  to  soft  tissues? 

44.  Give  the  five  causes  of  necrosis. 

45.  Name  and  define  the  varieties  of  necrosis. 

46.  What  is  gangrene  and  give  its  causes? 

47.  Name  the  varieties  of  gangrene. 

48.  What  is  suppurative  inflammation? 

49.  What  is  pus? 

50.  What  is  an  abscess? 

51.  What  is  an  ulcer? 

52.  What  is  a  sinus? 

53.  What  is  a  fistula? 


APPENDIX  437 

CHAPTER   II 

54.  Name  the  non-specific  infections. 

55.  What  bacteria  usually  cause  cellulitis? 

56.  Describe  the  clinical  features  of  cellulitis. 

57.  Give  the  treatment  of  cellulitis. 

58.  What  is  sapremia? 

59.  Give  the  symptoms  of  sapremia. 

60.  Give  the  treatment  of  sapremia. 

61.  What  is  septicemia? 

62.  Give  the  symptoms  and  treatment  of  septicemia. 

63.  What  is  pyemia? 

64.  Give  the  differential  symptoms  between  septicemia  and  pyemia. 

65.  What  diseases  are  liable  to  be  confused  with  pyemia? 

CHAPTER   III 

66.  What  is  erysipelas? 

67.  What  is  the  germ  producing  erysipelas? 

68.  What  pathological  changes  take  place  in  the  tissues  in  ery- 

sipelas ? 

69.  Give    the   local   symptoms    of   erysipelas;   the   constitutional 

symptoms. 

70.  What  are  the  varieties  of  erysipelas? 

71.  From  what  diseases  must  erysipelas  be  differentiated? 

72.  What  is  the  prognosis  of  erysipelas? 

73.  Give  the  local  treatment  of  erysipelas ;  the  constitutional  treat- 

ment. 

74.  What  is  actinomycosis? 

75.  What  microorganisms  produce  actinomycosis  ? 

76.  What  tissues  of  the  mouth  is  mycosis  likely  to  involve? 

77.  Give  the  treatment  of  mycosis. 

78.  What  is  tetanus? 

79.  "^Vhat  variety  of  bacterium  causes  tetanus  and  how  does  the 

infection  occur? 

80.  Give  the  symptoms  and  treatment  of  tetanus. 

81.  What  is  hydrophobia  and  how  does  the  inoculation  occur? 

82.  Give  the  symptoms,  prophylaxis  and  treatment  of  hydrophobia. 

83.  What  is  anthrax? 

84.  How  is  diagnosis  of  anthrax  made? 

85.  What  serum  is  used  in  the  treatment  of  anthrax? 


438  APPENDIX 

CHAPTER   IV 

86.  What  is  tuberculosis? 

87.  What  are  the  four  principal  etiological  factors  of  tubercu- 

losis ? 

88.  Give  the  avenues  of  entrance  of  the  bacillus  of  tuberculosis 

into  the  body. 

89.  Describe  the  pathology  of  a  tubercle. 

90.  What  is  the  general  course  of  tuberculosis? 

91.  What  tissues  are  likely  to  be  involved? 

92.  What  are  the  usual  fates  of  a  tubercle? 

93.  Give  the  general  and  local  treatment  of  tuberculosis. 


CHAPTER   V 

94.  What  are  the  venereal  diseases? 

95.  How  are  the  venereal  diseases  usually  transmitted? 

96.  Give  the  definition  of  gonorrhea. 

97.  Give  the  name  and  classification  of  the  germ  of  gonorrhea. 

98.  What  tissues  are  usually  infected  and  what  other  tissues  may 

be  infected  in  gonorrhea? 

99.  What  are  the  complications  of  gonorrhea? 

100.  What  are  the  remote  serious  results  of  gonorrhea? 

101.  Give  the  treatment  for  gonorrhea. 

102.  What  is  chancroid  ? 

103.  In  what  way  is  chancroid  transmitted? 

104.  Describe  the  characteristic  sore  of  chancroid. 

105.  What  is  meant  by  autoinoculation  as  applied  to  chancroid? 

106.  What  are  the  complications  of  chancroid  ? 

107.  Give  the  treatment  for  chancroid. 

108.  Is  chancroid  a  constitutional  disease? 

109.  Give  the  definition  of  syphilis. 

110.  By  whom  and  in  what  year  was  the  microorganism  of  syphilis 

demonstrated  ? 

111.  Name  and  define  the  microorganism  of  syphilis. 

112.  Where  is  the  microorganism  of  syphilis  found? 

113.  What   is   meant  by   the  Noguchi   and   the  Wassermann   re- 

actions ? 


APPENDIX  439 

114.  What  are  the  modes  of  contagion  of  syphilis? 

115.  What  is  Colles'  Law? 

116.  Give  the  stages  and  periods  of  syphilis. 

117.  Define  the  primary  lesion  of  syphilis,  giving  its  appearance. 

118.  What  are  the  complications  of  the  first  stage  of  syphilis? 

119.  Give  eight  points  in  making  a  diagnosis  of  chancre. 

120.  What  are  secondary  lesions? 

121.  When  in  relationship  to  time  of  the  chancre  do  the  secondary 

lesions  generally  occur? 

122.  Give  the  usual  secondary  lesions. 

123.  Define  tertiary  lesions. 

124.  When  in  relationship  to  time  may  the  tertiary  lesions  occur  ? 

125.  What  is  the  difference  in  the  course  and  the  effect  upon  the 

tissues  between  the  secondary  and  the  tertiary  lesions? 

126.  What  are  the  usual  lesions  of  tertiary  syphilis? 

127.  Give  the  pathology  of  a  gumma. 

128.  How  does  syphilis  attack  the  bones? 

129.  Where  are  gummata  usually  located? 

130.  What  is  hereditary  syphilis? 

131.  Describe  the  appearance  of  a  syphilitic  child. 

132.  What  is  the  prognosis  in  the  various  stages  of  syphilis  ? 

133.  In  what  stages  of  syphilis  is  the  disease  most  virulently  in- 

oculable  and  when  is  it  not  inoculable? 


CHAPTER  VI 

134.  Classify  wounds,  giving  a  brief  description  of  each  class. 

135.  Describe     the     difference     between     arterial     and     venous 

hemorrhage. 

136.  How  is  external  hemorrhage  controlled? 

137.  What  is  internal  hemorrhage  and  where  may  it  occur? 

138.  How  is  internal  hemorrhage  controlled  in  the  various  organs 

of  the  body  ? 

139.  Give  the  treatment  of  burns  and  scalds  from  various  causes. 

140.  Give  the  differential  symptoms  of  concussion  and  compression 

as  applied  to  injuries  of  the  brain  and  skull. 

141.  What  should  be  done  in  cases  of  foreign  bodies  in  the  follow- 

ing locations :  eye  ;  nose ;  throat ;  larynx ;  stomach  ? 


440  APPENDIX 

CHAPTER  VII 

142.  Give  the  uses  of  bandages. 

143.  What  materials  are  used  in  making  bandages? 

144.  Name  the  varieties  of  bandages. 

145.  Give  the  uses  of  a  roller  bandage. 

146.  Give  the  uses  of  a  triangular  bandage. 

147.  Describe  a  Barton  bandage. 

CHAPTER    VIII 

148.  What  is  shock  ? 

149.  Give  the  symptoms,  diagnosis  and  treatment  of  shock. 

150.  Name  and  briefly  define  the  following  terms :  coma ;  apoplexy ; 

asphyxia ;  epilepsy. 

151.  Give  the  usual  causes  of  convulsions  in  children  and  the  usual 

prognosis  and  treatment. 

152.  What  diseases  of  the  kidneys  result  in  convulsions  and  what 

is  their  significance? 

CHAPTER   IX 

153.  Give  the  definitions  of  the  three  following  terms :  asepsis ;  sep- 

sis ;  antisepsis. 

154.  What  do  asepsis,  sepsis  and  antisepsis  mean  as  applied  to 

surgical  practice? 

155.  What  is  a  germicide  ? 

156.  Name  several  germicides,  giving  their  usual  strength  of  solu- 

tion and  method  of  use. 

157.  How  are  dressings  prepared  for  use  in  surgical  cases? 

158.  How  is  the  operating  room  prepared  for  surgical  cases? 

159.  How  is  the  patient  prepared  for  an  operation? 

160.  Define  the  terms  suture  and  ligature. 

161.  How  are  sutures  and  ligatures  used  and  of  what  materials 

are  they  made? 

CHAPTER  X 

162.  What  things  are  necessary  to  make  a  correct  diagnosis? 

163.  What  points  must  be  considered  in  making  a  case  history? 

164.  What  things  must  be  taken  into  consideration  in  obtaining  a 

complete  knowledge  of  a  disease  ? 


APPENDIX  441 

165.  Define  the  various  terms  used  in  studying  a  disease. 

166.  What  points  are  to  be  considered  in  making  a  medical  diag- 

nosis ? 

167.  What  is  meant  by  physical  diagnosis? 

168.  Define  the  following  terms  and  explain  their  scope   of  use- 

fulness: inspection;  mensuration;  palpation;  percussion; 
auscultation. 

169.  What  is  pulmonary  resonance? 

170.  What  is  dullness  and  what  does  it  indicate  ? 

171.  What  is  flatness  and  what  does  it  indicate? 

172.  What  is  a  rale  ? 

173.  What  is  tympanitis? 

174.  What  is  vesicular  murmur? 

CHAPTER   XI 

175.  How  are  the  diseases  of  the  heart  classified? 

176.  What  elements  produce  the  heart  sounds  and  what  are  they 

likened  unto? 

177.  To  what  diseases  are  the  heart  valves  subject  ? 

178.  WTiat  is  the  difference  between  regurgitation  and  stenosis  as 

applied  to  the  valves  of  the  heart  ? 

179.  Describe  pericarditis,  endocarditis,  hypertrophy   and  dilata- 

tion as  applied  to  disease  of  the  heart. 

180.  Give  the  usual  pulse  rate  and  tell  what  artery  is  made  use  of 

in  determining  the  character  of  the  pulse. 

181.  Describe  the  difference  between  a  frequent  and  a  quick  pulse. 

182.  What  drugs  increase  the  frec[uency  of  the  heart  and  what 

drugs  diminish  it? 

183.  What  are  the  diseases  of  the  blood  vessels? 

184.  What  diseases   are  likely  to   attack  the   walls  of  the   blood 

vessels  ?  ' 

185.  What  are  the  diseases  of  the  contents  of  the  blood  vessels? 

186.  What  is  aneurism  and  what  are  the  varieties? 

187.  What  is  angioma  ? 

188.  Name   and   describe   the   various   diseases   of  the    lymphatic 

system. 

189.  What  is  a  lymphangioma? 


442  APPENDIX 

PAET  II 

CHAPTER  XII 

1.  Is  there  a  difference  in  the  pathology  of  the  mouth  and  that 

of  other  parts  of  the  body? 

2.  Describe  the  complex  nature  of  the  mouth. 

3.  Name  the  many  functions  of  the  mouth. 

4.  Name  the  accessory  cavities  of  the  mouth. 

5.  Describe  the  mucous  membrane  of  the  mouth. 

6.  Name  the  disturbances  of  dentition. 

7.  "What  reflex  neuroses  may  result  from  dentition? 

8.  What  skin  lesions  are  observed  as  apparent  results  of  den- 

tition ? 

9.  Name  some  of  the  prominent  mouth  lesions  associated  witn 

general  or  constitutional  diseases. 

10.  What  effect  do  alcohol  and  tobacco  have  on  the  tissues  of  the 

oral  cavity? 

11.  What  can  be  said  regarding  the  presence  of  bacteria  m  the 

mouths  of  apparently  healthy  persons? 

12.  What  is  meant  by  Hutchinson's  teeth? 

13.  What  is  Black's  theory  regarding  the  cause  of  defects   of 

teeth  in  children? 

14.  Name  some  of  the  complications  of  extractions. 

15.  What  is  a  reflex  neurosis? 

16.  What  general  diseases  have  been  traceable  to  impacted  teeth, 

ulcerations,   and  other  defective   conditions  of  the  teeth 
and  peridental  structures? 

17.  What  general  diseases  of  the  nervous  system  have  been  trace- 

able to  diseased  of  the  mouth? 

CHAPTEH   XIII 

18.  What  bearing  has  alveolar  abscess  upon  the  production  of 

serious  lesions  of  the  facial  bones? 

19.  How  is  an  apical  cyst  developed  and  how  may  it  result  in 

more  serious  conditions? 


APPENDIX  443 

20.  In  what  way  does  infection  occur  in  alveolar  abscess? 

21.  Give  the  pathology  of  an  alveolar  abscess. 

22.  What  is  the  treatment  for  alveolar  abscess  of  the  mandible  ? 

23.  What  do  you  understand  by  blood  clot  organization  1 

24.  What  is  the  difference  between  the  course  of  an  alveolar  ab- 

scess in  the  mandible  and  one  in  the  maxilla? 

25.  What  cavities  may  be  perforated  from  diseased  teeth  in  the 

maxilla  ? 

26.  What  is  a  naso-oral  fistula? 

27.  Give  the  treatment  for  a  chronic  alveolar  abscess  where  the 

root  of  a  tooth  is  exposed  in  the  cavity. 


CHAPTER   XIV 

28.  Give  a  definition  for  stomatitis. 

29.  Give  the  two  general  divisions  of  mouth  lesions. 

30.  Name  the  varieties  of  stomatitis. 

31.  What  acute  constitutional  diseases  produce  mouth  lesions? 

32.  What  chronic  constitutional  diseases  produce  mouth  lesions? 

33.  What  drugs  produce  mouth  lesions? 

34.  Give   the   symptoms,    diagnosis   and   treatment   of    catarrhal 

stomatitis. 

35.  What  are  the  two  forms  of  ulcerative  stomatitis? 

36.  Give  the  symptoms  of  ulcerative  stomatitis. 

37.  Name  some  of  the  complications  of  ulcerative  stomatitis. 

38.  What  is  the  treatment  for  ulcerative  stomatitis? 

39.  Give   the   symptoms,    diagnosis   and  treatment    for    herpetic 

stomatitis. 

40.  Give  a  description,  diagnosis  and  treatment  of  mycosic  stoma- 

titis. 

41.  Give  the  differential  symptoms  between  mycosic  stomatitis  and 

diphtheria. 

42.  Give  the   differential  symptoms  between  catarrhal  stomatitis 

and  ulcerative  stomatitis. 

43.  Differentiate  between  the  raotith  lesions  of  mercury  poisoning 

and  chronic  lead  poisoning. 

44.  What  are  the  mouth  lesions  from  pilocarpine  poisoning? 


444  APPENDIX 

45.  What  conditions  result  from  the  excessive  nse  of  iodine  1 

46.  Name   and   describe   some    of  the   skin   diseases   which  have 

mouth  lesions. 

47.  What  are  Koplik's  spots? 

48.  What  is  strawberry  ton^e? 

49.  What  is  perleche? 

50.  Give  the  definition  and  cause  of  Vincent's  angina. 

51.  Give  the  history  of  Vincent's  angina. 

52.  What  bacteria  produce  Vincent's  angina? 

53.  What  diseases  and  conditions  are  liable  to  be  confused  with 

Vincent's  angina? 

54.  Give  the  symptoms  of  Vincent's  angina. 

55.  What   are   the   clinical  features   in  the    lesion   of  Vincent's 

angina  ? 

56.  Give  the  diagnosis  of  Vincent's  angina. 

57.  What  is  the  prognosis  of  Vincent's  angina? 

58.  What  is  the  treatment  for  Vincent's  angina? 

CHAPTER   XV 

59.  Of  what  importance  to  the  dental  practitioner  is  the  study  of 

the  tongue? 

60.  What   clinical  signifioance   is   found   in  the   coating   of   the 

tongue  ? 

61.  What  does  a  beefy  or  red  tongue  indicate? 

62.  What  significance  do  the  different  colors  of  the  tongue  have? 

63.  What  significance  is  there  in  the  shape  of  the  tongue  in  diag- 

nosing general  diseases? 

64.  What  does  a  bitter  taste  indicate? 

65.  What  are  the  congenital  defects  of  the  tongue  and  briefly 

describe  each? 

66.  What  is  the  treatment  for  ankyloglossia  and  macroglossia  ? 

67.  Classify  the  acquired  affections  of  the  tongue. 

68.  Describe  glossitis,  giving  its  treatment. 

69.  What  is  Ludwig's  angina  and  what  is  the  treatment  for  it? 

70.  Describe  chronic  inflammation   of  the   tongue,   giving  cause 

and  treatment. 


APPENDIX  445 

71.  What  is  leucoplakia  of  the  month? 

72.  Give  a  description  of  the  tongne  in  leucoplakia. 

73.  What  diseases  must  be  differentiated  from  leucoplakia? 

74.  What  is  the  treatment  of  leucoplakia? 

75.  What  varieties  of  injury  is  the  tongue  liable  to? 

76.  What  is  lingual  goiter? 

77.  Name  the  tumors  of  the  tongue. 

78.  What  are  the  steps  required  to  differeniiate  between  benign 

and  malignant  tumors  of  the  tongue  ? 

79.  Should  operations  be  performed  on  the  tongue  before  micro- 

scopic examinations  are  made? 

80.  What  diseases  are  liable  to  be  mistaken  for  malignant  dis- 

eases of  the  tongue? 

81.  What  is  the  treatment  for  benign  tumors  of  the  tongue? 

82.  What  is  the  treatment  for  malignant  diseases  of  the  tongue  ? 

CHAPTER    XVI 

83.  What  are  the  characteristic  features  of  a  healthy  face? 

84.  What  pathological  conditions  should  be  observed  in  the  first 

glance  in  the  study  of  a  face? 

85.  What  is  erythema? 

86.  What  is  meant  by  the  following  terms:  petechia;   macula; 

papule;  vesicle;  pustule? 

87.  What  is  dermatitis? 

88.  What  is  acne  vulgaris? 

89.  What  is  the  difference  between  comedo  and  milium? 

90.  Give  the  pathology  and  treatment  of  a  sebaceous  cyst. 

91.  What  is  verruca  ? 

92.  Give  the  pathology  of  verruca. 

93.  What  are  skin  horns? 

94.  Differentiate  between  tinea  sycosis  and  tinea  triehophytina. 

95.  Give  the  pathology  and  treatment  of  carbuncle  and  furuncle. 

96.  What  is  neurosis  of  the  face? 

97.  Give  the  differential  points  between  nyperesthesia  and  anes- 

thesia. 

98.  Give  the  difference  between  hypertrophy  and  atrophy. 


446  APPENDIX 

CHAPTER    XVII 

99.  Give  the  classification  of  general  bone  diseases. 

100.  "What  is  general  infective  osteomyelitis? 

101.  What  bacteria  produce  general  infective  osteomyelitis? 

102.  What  pathological  changes  occur  in  general  osteomyelitis? 

103.  What  is  a  sec[uestrum  as  applied  to  bone  disease? 

104.  What  is  acute  circumscribed  osteomyelitis? 

105.  What  is  chronic  circumscribed  osteomyelitis? 

106.  What  is  acute  diffused  osteomyelitis? 

107.  "What  is  chronic  diffused  osteomyelitis? 

108.  Differentiate  acute  general  from  circumscribed  osteomyelitis. 

109.  Differentiate   chronic   circumscribed  from  diffused   osteomye- 

litis. 

110.  What  are  the  complications  of  infective  bone  disease? 

111.  AMiat  is  the  treatment  for  infective  bone  disease? 

112.  WTiat  is  bloodclot  organization? 

113.  Describe  the  method  of  repair   after  bone   destruction   and 

operation. 

114.  Classify^  periostitis. 

115.  Give  the  pathological  changes  in  acute  suppurative  periostitis. 

116.  What  general  diseases  produce  disease  of  the  bones? 

CHAPTER   XYIII 

117.  Give  the  etiological  classification  of  diseases  of  the  mandible. 

118.  WTiat  is  necrosis  as  applied  to  bone  disease? 

119.  Hov"  may  the  use  of  the  hypodermic  syringe  cause  necrosis 

of  the  alveolar  process? 

120.  What  are  the  causes  of  alveolar  necrosis? 

121.  Give  the  symptoms  of  alveolar  necrosis. 

122.  Give  the  treatment  of  alveolar  necrosis. 

123.  Describe  the  sjmiptoms  of  acute  periostitis  of  the  body  of  the 

mandible. 

124.  WTiat  is  the  treatment  for  acute  periostitis  of  the  body  of 

the  mandible? 

125.  Give  the  cause  of  osteomyelitis  of  the  body  of  the  mandible. 

126.  Give  the  treatment  for  osteomyelitis  of  the  body  of  the  man- 

dible. 


APPENDIX  447 

127.  What   is  meant  by  chemical  necrosis   and   what    drugs   pro- 

duce destruction  of  bone? 

128.  Describe  phosphorus  necrosis  of  bone,  giving  its  management. 

129.  How  may  mercury  produce  necrosis? 

130.  What  are  the  characteristic  symptoms  of  the  early  stage  of 

mercurial  necrosis? 

131.  How  does  arsenic  result  in  death  of  bone? 

132.  What  is  exanthematous  necrosis  and  of  what  diseases  is  it  a 

sequela  ? 

CHAPTER    XIX 

133.  Give  the  symptoms  of  acute  suppuration  of  the  maxilla. 

134.  What  is  the  treatment  for  acute  suppuration  of  the  maxilla? 

135.  Where  should  incision  be  made  for  abscess  of  the  maxilla? 

136.  What  are  the  complications  of  destruction  of  the  maxilla? 

137.  What  is  a  naso-oral  fistula  ? 

138.  Describe  the  operation  for  closure  of  a  naso-oral  fistula. 

139.  Is  tuberculosis  a  common  cause  of  necrosis  of  the  maxilla? 

140.  How  may  tabes  dorsalis  cause  facial  bone  disease? 

141.  What   is   acromegaly   and   what   bones   are   most   frequently 

hypertrophied  ? 

142.  What  is  leontiasis  ossea,  and  in  what  way  does  it  produce 

symptoms  in  the  dental  field  of  operation? 

143.  How  is  bone  regenerated  after  destruction? 

144.  What  would  be  your  practice  in  a  case  of  destruction  of  the 

entire  body  of  the  maxilla  as  regards  removal? 

145.  What  is  the  advantage  in  leaving  the  sequestrum  in  the  mouth 

even  after  it  is  detached? 

146.  What  is  meant  by  the  following  terms  as  applied  to  bone 

disease:  papilla;  sinus;  chloaca;  involucrum;  sequestriun? 

147.  Describe  the  technique  of  operations  upon  the  alveolar  proc- 

ess. 

148.  Would  you  incise  through  the  skin  in  operations  upon  the 

maxilla  or  mandible ;  if  not,  why  not  ? 

CHAPTER  XX 

149.  In  what  forms  do  tuberculous  lesions  appear  on  the  face? 

150.  Give  the  symptoms  and  pathology  of  scrofuloderma. 

151.  What  is  tuberculosis  cutis? 


448  APPENDIX 

152.  What  is  the  pathology  of  lupus  vulgaris? 

153.  Differentiate  lupus  vulgaris  from  lupus  exedens. 

154.  Differentiate  syphilitic  ulcer  of  the  face  from  lupus  vulgaris. 

155.  Give  the  treatment  for  tuberculous  diseases  of  the  skin. 

156.  What  are  the  characteristic  mouth  lesions  of  tuberculosis? 

157.  Describe  a  characteristic  tuberculous  ulcer  of  the  mouth. 

158.  What  are  the  usual  tuberculous  diseases  of  the  bones  of  the 

face? 

159.  Grive  the  treatment  of  tuberculosis  of  the  mouth. 

CHAPTER  XXI 

160.  What  is  the  danger  to  the  dentist  in  operations  upon  the 

mouths  of  syphilitic  patients? 

161.  Is  it  common  for  dentists  to  become  inoculated  with  syphilis 

from  their  patients  ? 

162.  What  is  the  appearance  of  an  initial  lesion  of  the  mouth? 

163.  What  are  the  usual  secondary  manifestations  as  found  in  the 

mouth  ? 

164.  What  are  the  tertiary  lesions  of  the  mouth? 

165.  In  hereditary  syphilis  where  are  the  lesions  to  be  found? 

166.  Differentiate  an  initial  lesion  from  a  secondary  patch. 

167.  Differentiate  a  secondary  patch  from  a  gumma. 

168.  Differentiate  a  secondary  patch  from  ulcerative  stomatitis. 

169.  In  what  stages  is  syphilis  virulently  inoeulable  and  in  what 

stages  and  varieties  is  it  not  inoeulable  ? 

170.  Differentiate  a  gumma  of  the  mouth  from  an  epithelioma. 

171.  Differentiate  gumma    from   a  tuberculous  ulceration   of  the 

mouth. 

172.  What  is  sclerosing  glossitis? 

173.  What  is  specific  ulcerative  gingivitis? 

174.  Classify  the  syphilitic  diseases  of  the  facial  bones. 

175.  Give  the  symptoms  of  syphilitic  bone  disease. 

176.  What   diseases  must  be   differentiated  from  syphilitic   bone 

disease  ? 

CHAPTER    XXII 

177.  What  is  a  tumor? 

178.  How  are  tumors  distinguished  from  inflammatory  conditions 

and  hypertrophies? 

179.  Give  the  theories  as  to  the  etiology  of  tumors. 


APPENDIX  449 

180.  Give  the  histological  classification  of  tumors. 

181.  Give  the  clinical  classification  of  tumors. 
182    Give  White 's  classification  of  tumors. 

183.  Describe  fibroma  and  give  its  pathology,  varieties  and  treat- 

ment. 

184.  Describe  lipoma  and  give  its  pathology,  varieties  and  treat- 

ment. 

185.  Describe  adenoma  and  give  its  pathology,  varieties  and  treat- 

ment. .      .  14.+ 

186.  Describe  neuroma  and  give  its  pathology,  varieties  and  treat- 

ment. 

187.  Describe  cystoma  and  give  its  pathology,  varieties  and  treat- 

ment 

188.  Give  the 'classification  of  the  non-infective  tumors  of  the  soft 

tissues  of  the  mouth. 

189.  What  are  cysts  of  the  glands  of  Nuhn  and  where  are  they 

located^ 

190.  Give  the  general  divisions  of  tumors  of  the  alveolar  process. 

CHAPTER   XXIII 

191    What  are  developmental  tumors  of  the  teeth? 

192^  Give  the  probable  histology  of  developmental  tumors  of  the 

teeth. 
193    Give  Sutton's  classification  of  odontomata. 
194'.  From  what  tissues  does  an  epithelial  odontome  develop? 
195.  What  is  a  follicular  odontome? 
196    What  is  a  dentigerous  cyst? 
197'  What  is  the  pathology  of  follicular  odontomata? 
198.  What  are  cementous  follicular  odontomata? 

199  What  are  reticular  odontomata? 

200  Why  is  the  term  composite  odontomata  used? 
901    Give  the  general  symptoms  of  odontomata. 

f02:  mat  toes  Broca  s'ay  regarding  the  ^^^^'^^^^ 
203.  Give  the  characteristic  symptoms  during  the  course  ot 

velopment  of  odontomata. 
904    At  what  age  do  odontomata  develop? 
205    From  wha?  other  pathological  conditions  of  the  alveolar  proe- 

205.  From  wh  ^  ^,^J^^.^^  ^.^^^.^  „j  odontomata  to  be  made! 

206.  What  is  the  treatment  for  odontomata? 


450  APPENDIX 

CHAPTER  XXIV 

207.  Name  the  most  common  forms  of  the  neoplasms  of  the  alveolar 

soft  tissues. 

208.  Differentiate  papilloma  from  polypus  of  the  alveolar  process. 

209.  What  is  hypertrophy  of  the  mucous  membrane  of  the  alveolar 

process? 

210.  What  is  epulis? 

211.  How  many  varieties  of  epulis  are  recognized? 

212.  What  is  the  difference  between  the  varieties  of  epulis  as  re- 

gards prognosis  ? 

213.  What  is  chloroma? 

214.  Give  history  and  prognosis  of  chloroma. 

215.  What  are  the  bone  tumors  and  cysts  of  the  alveolar  process? 

216.  Differentiate  an  exostosis  from  an  osteoma. 

217.  What  conditions  cause  cysts  of  bones? 

218.  M^iat  is  the  treatment  for  bone  cysts? 

219.  What  are  the  essential  points  in  operating  upon  bone  cysts 

and  why  may  they  return  ? 

CHAPTER   XXV 

220.  What  is  sarcoma? 

221.  Give  the  varieties  of  sarcoma. 

222.  Give  the  prognosis  and  treatment  of  sarcoma. 

223.  How  does  sarcoma  attack  the  tissues  of  the  mouth? 

224.  What  tissues  are  most  likely  to  be  attacked  by  sarcoma? 

225.  Give  the  symptoms  of  sarcoma  of  the  tissues  of  the  oral  cavity. 

226.  Give  the  treatment  for  sarcoma  of  the  tissues  of  the  mouth. 

227.  What  is  carcinoma? 

228.  Give  the  three  varieties  of  carcinoma. 

2?P    What  is  lupus  exedens  and  differentiate  it  from  lupus  vulgaris  ? 

230.  What  is  the  treatment  for  epithelioma  of  the  skin  ? 

231.  What  is  tubular  carcinoma  and  what  tissues  does  it  attack? 

232.  What  is  acinous  carcinoma  ? 

233.  Describe  epithelioma  of  the  mouth. 

234.  Differentiate   epithelioma   of   the   mouth    from   other    mouth 

lesions. 

235.  What  is  the  treatment  for  epithelioma  of  the  mouth? 


APPENDIX  451 

CHAPTER    XXVI 

236.  What  are  the  diseases  that  are  likely  to  develop  from  fully 

developed  teeth  1 

237.  What  are  impacted  teeth? 

238.  What  are  the  symptoms  of  impacted  teeth  without  a  sinus? 

239.  What  are  the  symptoms  of  impacted  teeth  with  a  sinus? 

240.  What  teeth  are  most  frequently  impacted? 

241.  AVhat  is  the  position  of  an  impacted  third  molar  and  why 

does  it  assume  this  position? 

242.  What  complications  are  likely  to  be  associated  with  impac- 

tions of  teeth? 

243.  What  is  the  treatment  for  impacted  teeth  ? 

244.  May  cystic  tumors  of  the  alveolar  process  develop  during  the 

eruption  of  teeth? 

245.  What  is  the  treatment  of  cystic  tumors  of  the  alveolar  process  ? 

246.  What  is  a  cyst  from  the  root  of  a  developed  tooth? 

247.  What  is  the  pathology  of  a  cyst  from  the  root  of  a  developed 

tooth  ? 

CHAPTER  XXVII 

248.  What  are  the  usual  congenital  defects  of  the  face  and  mouth? 

249.  Describe  the  embryology  of  the  development  of  the  face. 

250.  What  is  the  intermaxillary  process? 

251.  What  is  the  cause  of  harelip  and  cleft  palate? 

252.  Why  is  harelip  never  in  the  median  line? 

253.  What  are  some  of  the  minor  congenital  defects  of  the  face 

and  mouth? 

254.  What  are  the  causes  of  acquired  cleft  palate  ? 

CHAPTER  XXVIII 

255.  Give  the  clinical  varieties  of  harelip. 

256.  What  is  the  prognosis  in  cases  of  harelip  ? 

257.  Describe  an  operation  for  complete  unilateral  harelip. 

258.  Describe  an  operation  for  incomplete  unilateral  harelip. 

259.  Describe  an  operation  for  complete  bilateral  harelip. 

260.  What  sutures  are  usually  used  for  closure  of  harelip? 

261.  What  is  the  usual  practice  regarding  dressings  after  opera- 

tions for  harelip  ? 


452  APPENDIX 

CHAPTEPt  XXIX 

262.  Give  the  history  of  cleft  palate  operations. 

263.  Give  the  causes  of  cleft  palate. 

264.  Give  the  clinical  varieties  of  cleft  palate. 

265.  What  are  the  ar^ments  in  favor  of  early  and  those  in  favor 

of  late  operations  for  cleft  palate  ? 

266.  What  anesthetic  is  best  for  operations  for  cleft  palate? 

267.  What  is  the  difference  between  uranoplasty  and   staphylo- 

plasty ? 

268.  What  are  the  usual  causes  of   failure  of  union  after  cleft 

palate  operations? 

269.  What  are  the  arguments  for  and  against  approximation  of  the 

maxillary  bones  in  infancy  for  cleft  palate  cases? 

270.  What  is  the  best  position  for  the  patient  in  cleft  palate  opera- 

tion? 

271.  What  instruments  are  used  in  cleft  palate  operations? 

272.  Name  the  varieties  of  operation  for  cleft  palate. 

273.  Describe  uranoplasty. 

274.  Describe  operation  for  cleft  of  the  alveolar  process. 

275.  Describe  operation  for  bilateral  complete  cleft  palate. 

276.  What  suture  materials  are  usually  used  in  cleft  palate  opera- 

tions ? 

277.  Describe  Ferguson's  operation  for  unilateral  cleft  palate. 

278.  Describe   a   method    of   introducing   sutures   in   cleft    palate 

operations. 

CHAPTER    XXX 

279.  Name  the  sinuses  accessory  to  the  nasal  cavity. 

280.  Describe  the  mucous  membrane  of  the  nose  and  its  extensions. 

281.  What  cavities  are  partly  formed  by  the  maxillary  bones  ? 

282.  Describe  the  cavity  of  the  maxillary  bone  in  detail,  giving 

its  shape,  foramina  of  exit,  etc. 

283.  What  is  the  relationship  of  the  maxillary  sinus  to  the  alveolar 

process  at  the  first  molar? 

284.  Give  the  anatomical  relationship  of  the  orifice  of  the  frontal 

sinus  to  that  of  the  maxillary  sinus. 

285.  In  what  way  may  the  antrum  become  infected  from  the  fron- 

tal sinus? 


APPENDIX  453 

286.  Give  the  etiological  classification  of  diseases  of  the  maxillary 

sinus,  giving  the  divisions  and  subdivisions. 

287.  How  is  the  maxillary  diseased  from  the  teeth  ? 

288.  What  conditions  produce  acute  infections  of  the  maxillary 

sinus  ? 

289.  What  are  the  growths  found  in  the  maxillary  sinus? 

290.  Give  the  symptoms  of  suppurative  antral  disease. 

291.  Name  the  principal  diagnostic  points  to  be  considered  in  sup- 

purative antral  disease. 

292.  Give  the  differential  diagnosis  of  suppurative  disease  of  the 

antrum. 

293.  What  is  the  prognosis  in  suppurative  antral  disease? 

294.  Give  a  brief  outline  of  the  treatment  of  suppurative  antral 

disease. 

295.  Describe  two  operations  for  the  purpose  of  entering  the  antral 

cavity. 

296.  What  is  your  idea  as  to  the  use  of  canula  after  opening  the 

antrum  into  the  mouth? 

297.  What  destructive  bone  diseases  are  likely  to  have  as  a  compli- 

cation antral  suppuration? 


CHAPTEE  XXXI 

298.  Give  definition  of  neuralgia. 

299.  Name  some  causes  of  neuralgia  of  the  fifth  nerve. 

300.  Give  the  symptoms  of  neuralgia  of  the  fifth  nerve. 

301.  At  what  points  do  the  three  divisions  of  the  fifth  nerve  come 

nearest  to  the  surface? 

302.  What  does  tenderness  of  these  points  indicate? 

303.  Give  the  differential  points  between  neuralgia  and  other  dis- 

eases of  the  same  region. 

304.  What  is  the  prognosis  of  neuralgia  ? 

305.  How  is  the  treatment  of  neuralgia  divided  ? 

306.  Give  the  medical  treatment  of  neuralgia. 

307.  How  is  neuralgia  treated  by  injections? 

308.  What  is  the  usual  solution  used  in  injections  for  neuralgia? 

309.  Describe  a  deep  injection  of  the  second  division  of  the  fifth 

nerve. 


454     ,  APPENDIX 

310.  What  are  the  peripheral  operations  for  neuralgia  of  the  fifth 

nerve  ? 

311.  What  is  the  difference  between  neurotomy  and  neurectomy? 

312.  What  are  the  deep  operations  for  neuralgia  of  the  fifth  nerve? 

313.  What  is  the  comparative  value  of  deep  operations  as  against 

deep  injections  of  alcohol? 

CHAPTER  XXXII 

314.  What  are  the  congenital  defects  of  the  salivary  glands? 

315.  Divide  the  diseases  of  the  salivary  glands. 

316.  Give  the  symptoms,  complications  and  treatment  of  acute  in- 

fection of  the  parotid  gland. 

317.  Give  the  symptoms  and  treatment  of  suppuration  of  the  sali- 

vary glands. 

318.  What  are  the  causes  of  fistula  of  the  salivary  glands? 

319.  What  is  the  treatment  of  external  fistula  of  Stenson's  duct? 

320.  What  is  salivary  calculus? 

321.  In  what  ducts  are  salivary  calculi  usually  found? 

322.  What  is  the  treatment  for  salivary  calculus  of  Wharton's 

duct  ? 

323.  Why  is  it  best  to  open  a  salivary  duct  within  the  mouth? 

324.  What  other  conditions  obstruct  the  salivary  duct? 

325.  What  is  ranula? 

326.  What  ducts  are  usually  obstructed  in  ranula  ? 

327.  Give  the  treatment  for  ranula. 

328.  What  conditions  cause  tumors  of  the  salivary  glands? 

CHAPTER  XXXIII 

329.  Give  a  definition  of  ankylosis. 

330.  What  joint,  M^hen  ankylosed,  is  of  the  greatest  importance  to 

the  dentist? 

331.  Classify  the  causes  of  disease  of  the  temporo-mandibular  joint. 

332.  Give  the  causes  of  temporary  ankylosis. 

333.  How  do  impacted  and  erupting  teeth  cause  ankylosis? 

334.  What  is  the  treatment  for  temporary  ankylosis  ? 

335.  What  are  the  causes  of  permanent  ankylosis  ? 

336.  Describe  an  operation  for  fibrous  ankylosis. 


APPENDIX  455 

337.  Describe  an  operation  for  permanent  ankylosis  from  destruc- 

tion of  the  temporo-mandibular  joint. 

338.  Describe  a  method  of  making  section  of  the  mandible. 

CHAPTER  XXXIV 

339.  What  is  fracture? 

340.  Give  the  general  varieties  of  fracture. 

341.  How  do  fractures  occur  through  bones? 

342.  In  what  way  are  fragments  displaced  in  fracture? 

343.  "What  are  the  causes  of  fracture? 

344.  What  are  the  symptoms  in  fracture? 

345.  What  are  the  three  cardinal  symptoms  in  fracture? 

346.  What  are  the  complications  of  fracture? 

347.  How  does  repair  occur  after  fracture? 

348.  Give  the  treatment  of  general  fracture. 

CHAPTER  XXXV 

349.  Why  is  fracture  of  the  mandible  a  frequent  accident? 

350.  Give  the  points  of  fracture  of  the  mandible  in  order  of  fre- 

quency. 

351.  What  are  the  causes  of  fracture  of  the  mandible  ? 

352.  What  are  the  symptoms  of  fracture  of  the  mandible? 

353.  What  are  the  complications  of  fracture  of  the  mandible? 

354.  Why  is  fracture  of  the  mandible  usually  compound? 

355.  Give  six  methods  of  treatment  for  fracture  of  the  mandible. 

356.  How  are  wire  splints  applied  in  fracture  of  the  mandible  ? 

357.  Describe  Angle 's  method  of  treating  fracture  of  the  mandible. 

358.  Describe  bone  wiring  and  why  it  is  resorted  to. 

359.  What  is  an  interdental  splint  and  what  is  its  value  in  the 

treatment  of  fracture  of  the  mandible  ? 

360.  What  is  the  value  of  external  bandages  and  appliances  and 

why  are  they  not  effective  ? 

CHAPTER  XXXVI 

361.  What  are  the  causes  of  fracture  of  the  maxilla? 

362.  What  are  the  usual  lines  of  fracture  of  the  maxilla  ? 

363.  In  what  way  may  fracture  of  the  maxilla  result  from  extrac- 

tions ? 

364.  What  are  the  complications  of  fracture  of  the  maxilla  ? 


456  APPENDIX 

365.  How  would  you  treat  a  fracture  of  the  maxilla  with  displace- 

ment of  the  fragment  ? 

366.  Describe  the  splint  used  to  hold  a  fracture  of  the  maxilla  in 

position  and  tell  how  it  is  applied. 

367.  What  are  the  usual  causes  of  fracture  of  the  nasal  bone? 

368.  What  are  the  complications  of  fracture  of  the  nasal  bene? 

369.  What  is  the  treatment  for  fracture  of  the  nasal  bone? 

370.  Why  is  fracture   of  the  malar  bone   of   importance   to   the 

dentist  ? 

371.  What  cavity  is  likely  to  be  injured  or  infected  in  fracture  of 

the  malar  bone? 

372.  How  is  depressed  fracture  replaced? 

373.  Why  is  fracture  of  the  zygomatic  arch  of  importance  to  the 

dentist  ? 

CHAPTER  XXXVII 

374.  What  is  dislocation? 

375.  Name  the  varieties  of  dislocation. 

376.  Name  the  structures  entering  into  the  formation  of  a  joint. 

377.  What  joints  of  the  body  are  most  frequently  dislocated? 

378.  What  are  the  causes  of  dislocation  in  general  ? 

379.  What  are  the  symptoms  of  dislocation  in  general? 

380.  How  is  dislocation  diagnosed? 

381.  What  are  the  complications  of  dislocation? 

382.  What  are  the  principal  points  in  treating  dislocation? 

383.  What  are  the  forms  of  dislocation  of  the  mandible? 

384.  What  are  the  causes  of  dislocation  of  the  mandible? 

385.  Give  the  anatomy  and  mechanism  of  a  dislocated  mandible. 

386.  What  are  the  symptoms  of  a  dislocated  mandible? 

387.  How  would  you  reduce  a  unilateral  dislocation  of  the  man- 

dible? 

388.  How  would  you  reduce  a  bilateral  dislocation  of  the  man- 

dible? 

389.  What  would  be  the  practice  in  chronic  dislocated  mandibles 

where  the  jaw  had  assumed  an  almost  normal  position 
before  examination? 

CHAPTER  XXXVIII 

390.  Describe  the  use  of  X-ray  pictures  to  the  dentist. 

391.  Describe  the  technique  of  taking  X-ray  pictures  of  teeth. 


INDEX 


INDEX 


A 


Abscess,  14. 

Absorption  of  bacteria,  104. 

Aeheilia,  306. 

Acinous  carcinoma,   282. 

Acne  vulgaris,   161. 

Acquired  affections  of  tong'ue,  149. 

Acquired  deformities,  308. 

Acromegaly,  197. 

Actinomycosis,  26. 

Acute  osteomyelitis,   173. 

Addison's  disease,  140. 

Adenoids,   306. 

Adenoma,  241. 

Alcohol,  effects  of,  on  mouth,  103. 

injections  of,   357. 
Alveolar   abscess,   105. 

as  cause  of  bone  disease,  115. 

infective  causes  of,  113. 

mechanical  causes   of,   112. 

non-infective  causes  of,  112. 

operation   for,    114. 

papilloma  from,  118. 

pathology  of,   114. 

treatment  of,   116. 

X-ray  of,   118. 
Alveolar  necrosis,  180. 
Alveolar  sarcoma,  276. 
Anesthesia,  170. 
Aneurism,  94. 
Angina,  Ludwig's,  150. 

Vincent's,   141. 
Angina  pectoris,   91. 
Angioma,   95,   245. 
Angle's  method,   396. 
Ankylogiossia,  147. 
Ankylosis,  cause  of,  377. 

classification  of,  376. 

fibrinous,  379. 


Ankylosis,  osseous,  380,  388. 
peiTiianent,  378. 
temjoorary,  377. 
treatment  of,   379. 
Anthrax,  30. 
Antisepsis,   75. 

Antrum,   acute  infections  of,  344. 
diseases  of   walls   of,  338. 
classification  of,  340. 
injuiies   as  cause  of,  343. 
neoplasms  in,  345. 
ojjerations  for,  350. 
nasal  route  in,  351. 
oral  route  in.,  350. 
teeth  as  cause  of,  342. 
X-ray  of,  340. 
empyema   of,   345. 
suppuration  of,  345. 
Aphthous  stomatitis,  129. 
Apoplexy,   72. 
Arsenic  necrosis,  188. 
Arteries,     calcareous     degeneration 
of,   93. 
coats  of,  92. 
diseases  of  walls  of,  92. 
fatty  degeneration  of,  93. 
Asepsis,    75. 
Asphyxia,   73. 
Astomia,   307. 
Atresia,   307. 
Atrophy,  of  face,  170. 

of  teeth,  107. 
Auscultation,   85. 


B 


Bacteria,  absorption  of,  104. 
Black's    study    of,    104. 
composition   of,   4. 
discovery  of,  3. 


459 


460 


INDEX 


Bacteria,  effects  of,  5. 

in  dentition,  103. 

Miller's  study  of,  104. 

morphology  of,  3. 

Netter's  study  of,  104. 

of  mouth,  103,  123. 

of  osteomyelitis,  171. 

of  Vincent's  angina,  142. 

products  of,   5. 

reproduction  of,  4. 
Baldwin's  operation,   325. 
Bandaging,  66. 

roller  bandage,   67. 

triangular  bandage,  68. 
Barber's  itch,  165. 
Barton's  bandage,  403. 
Bell's  palsy,  110,   170. 
Blastomycosis,  165. 
"Bleeders,"   107. 
Bloodclot  organization,  176. 
"Boil,"   166. 
Bones,  cysts  of,  273. 

diseases  of,  classification  of,  171. 
iodin  in,  175. 
repair  in,  176. 

fractures  of,  391. 

intermaxillary,  301. 

malar  fracture  of,  415. 

nasal  fracture  of,  413. 

regeneration  of,  199. 

wiring  of,  397. 
Brain,  compression  of,  63. 

concussion  of,  63. 

injuries   to,  62. 
Brophy's  operation,  324. 
Burns,    60. 

treatment  of,  61. 


C 


Calcareous  degeneration,  93. 
Calculus,  salivary,  368. 
Callus,   391. 
Cancrum  oris,  130. 
Canker  sores,  125. 
Carbuncle,    167. 


Carcinoma,  279. 
acinous,   282. 
tubular,  282. 
Case  history,  80. 
Catarrhal  stomatitis,  124. 
Cellulitis,  16. 

Cementous  odontomata,  251. 
Chancre,  of  lip,  222. 
of  mouth,  222. 
of  tongue,  223. 
of  tonsil,  222. 
Chancroid,  37. 

primary  lesion  of,  40. 
Chemical  necrosis,   arsenic,  188. 
mercury,  187. 
phosphorus,   186. 
Chloroma,   269. 
Chronic  osteomyelitis,  174. 
Circumscribed  osteomyelitis,  174. 
Cleft,  of   face,  305. 

of  palate,  236,  316. 
Cleft   palate,   causes   of   failure   to 
unite  in,  319. 
etiology   of,   316. 
history  of,  316. 

operations  for,  anesthetics  in,  317. 
Baldwin's,  325. 
Brophy's,  324. 
Ferguson's,  329. 
instruments  in,  321. 
Lanelongue's,  330. 
Roe's,   328. 
sutures  in,  325,  332. 
time  of,  317. 
varieties  of,  322. 
statistics  of,   305. 
varieties  of,  316. 
Coating  of  tongue,  146. 
CoUes'  law,  39. 
Coloboma,    307. 
Coma,    72. 
Comedo,   161. 

Composite  odontomata,  254. 
Compression,  63. 
Concretions,  367. 

in  Wharton's  duet,  369. 
Concussion,  63. 


INDEX 


■iCl 


Congenital      defects,      absence      of 
salivary  glands,  364. 

of  face,  147. 

of  tongue,  147. 
Congestion,  10. 
Contusions,  54. 

of   face,    168. 
Convulsions,   74. 
Cryer's  section  of  face,  335. 
Cystic  tumors,  242. 
Cysts,    dentigerous,   250. 

dermoid,  244. 

echinocoecus,  244. 

fi'om  develoi^ed  teeth,  297. 

from  erupting  teeth,  294. 

muciparous,  243. 

multiple,  256. 

of  bone,  273. 

of  glands  of  Nuhn,  243. 

sebaceous,  163. 


D 


Deafness,  110. 
Defects,  congenital,  147. 

of  face,  305. 

of  tongue,  147. 
Deformities,  acquired,  308. 
Degeneration,  8. 
Dementia  precox,  109. 
Dentigerous  cysts,  250. 
Dentition,  bacteria  in,  103. 

digestive   disturbances  of,  102. 

neuroses  of,  102. 

skin  lesions  in,  103. 
Dermatitis,   161. 
Dermoid  cysts,   244. 
Development  of  face,  300. 

of  mouth,  300. 
Developmental  tumors,   248. 
Diagnosis,  general,  80. 

medical,  83. 

plij'sical,  84. 
Ditfei'ential  table,  134. 
Diffused  osteomyelitis,  173. 
Diphtheria,  137. 

mouth  lesions  in,  134. 


Diseases  of  bones,  classification  of, 
171. 
iodin  in,  175. 
repair  in,  176. 
Dislocations,  418. 
of  mandible,  422. 
anatomy  of,  423. 
reduction  of,  424. 
Ducts,  concretions  in,  369. 
fistula  of,  366. 
Stenson's,  166. 
Wharton's,  369. 


E 


Echinocoecus  cysts,   244. 
Ectropian,    307. 
Eczema  of  mouth,  138. 
Embryology,  300. 
Empyema  of  antrum,  345. 
Endocarditis,  90. 
Endothelioma,  246. 
Entropian,  307. 
Epilepsy,   73. 

Epithelial  odontomata,  250. 
Epithelioma,  271. 

of  mouth,  283. 

of  tongue,  157. 
Epulis,  264. 

fibroid,  266. 

myeloid,  267. 
Eruption  of  teeth,  102. 

cj^sts  from,  298. 
Erysipelas,  23. 
Erythema,  139. 

of  face,  160. 

of  fauces,  224. 
Etiology,  82. 

Exanthematous  necrosis,  192. 
Exostosis,  271. 

cause  of,  118. 
Extraction,  106. 

fracture  from,  410. 

hemorrhage  from,  107. 
Exudation,  8. 


462 


INDEX 


F 


Face,  atrophy  of,  170. 

clefts  of,  305. 

contusions    of,   168. 

Cryer's  section  of,  335. 

dermatitis   of,  161. 

development  of,  300. 

erythema  of,  160. 

hypertrophy  of,  170. 

Lathrop's  section  of,   337, 

macula  of,  160. 

neurosis  of,  169. 

papule  of,  160. 

petechia  of,  160. 

pustule  of,  161. 

spasms  of,  170. 

vesicle  of,  161. 

Avounds  of,  167. 
Fatty  degeneration,  93. 
Ferguson's  operation,  329. 
Ferments,  4. 

Fibrinous  ankylosis,  379. 
Fibroid  epulis,  264. 
Fibroma,  240. 

Fifth  nerve,  neuralgia  of,  353. 
Fistula,   14. 

naso-antral,  121. 

naso-oral,  120. 

of  ducts,  366. 
Fluorescence,  5. 
Follicular  odontomata,  250. 
Follicular  tonsillitis,  135. 
Foreign  bodies,  'in  the  ear,  64. 

in  the  eye,  63. 

in  the  larynx,  64. 

in  the  nose,  64. 

in  the  stomach,  65. 

in  the  throat,  64. 
Fracture,  bone  wiring  in,  397. 

callus  in,  391. 

from  extraction,  410. 

obstetric,   404. 

of  alveolar  process,  404. 

of  malar  bone,  415. 

of  mandible,  393. 

of  maxilla,  408. 


Fracture,  of  nasal  bones,  413. 

of  zygomatic  arch,  417.    • 

repair  of  bone  in,  391. 

splints  for,  397. 

varieties  of,  389. 
Frankel's  pneumococcus,  104. 
Fulminating  ecthyma,  139. 
Furuncle,  166. 

G 

Gag  for  mouth,  318. 
Gangrene,  12. 
Gangrenous  stomatitis,  131. 
Germicides,  76. 
Giant-celled  sarcoma,  275. 
Gingivitis,  syphilitic,  239. 

ulcerative,  230. 
Glands,  concretions  in,  367. 

fistula  of  ducts  of,  366. 

of   Nuhn,   243,   371. 

salivary,  364. 

sarcoma  of,  374. 

sebaceous,   161. 
Glossitis,  149. 

sclerosing,   229. 
Goiter,  lingual,  155. 
Gonorrhea,  35. 

complications  of,  36. 

treatment  of,  36. 
Gumma,   44. 

of   tonsil,  228. 

syphilitic,    227. 
Gunshot  wounds,  58. 


H 

Hare  lip,  bilateral,  313. 
complete,    314. 
dressings  for,  315. 
incomplete,  313. 
operations  for,  310. 

Malgaigne's,  311. 

Mirault-Langenbeck's.  312. 

Nekton's,  311. 
statistics  of,   305. 


INDEX 


4G3 


Hare  lip,  unilateral,  313. 

varieties  of,  310. 
Heart,  dilatation  of,  91. 

diseases  of,  88. 

hypertrophy  of,  90. 

murmurs  of,   88. 

sounds  of,  88. 

valves  of,  89. 
Hemangioma,   245. 
Hemori'hage,  58,  107. 

external,  59. 

internal,  59. 
Hereditary  syphilis,  234. 
Herpes,  123,  128. 
Herpes  zoster,  139. 
Herpetic  stomatitis,  128. 
Horns  of  nails  and  skin,  163. 
Hunterian  chancre,  41. 
Hutchinson's  teeth,  106. 
Hydrogen  dioxide,   77. 
Hydrophobia,  29. 
Hygiene,  oral,  103. 
Hyperemia,  10. 
Hyperesthesia,  170. 
Hyperostosis,  271. 
Hypertrophy,   alveolar,  263. 

of  face,  170. 

of  gum,  265. 

of  tongue,  148. 
Hysterical  occlusion,  388. 


Immunity,    6. 
Impacted  teeth,  288. 
Impetigo  contagiosa,  139. 
Incised  wounds,  55. 
Infections,   acute  antral,   344. 

as  cause  of  alveolar  abscess,  113. 
Inflammation,  of  tongue,  149. 

of  tonsil,  137. 

phenomena  of,  7. 

results  of,  11. 

symptoms  of,  7. 

varieties  of,   9. 

vascular  changes  in,  7. 
Initial  lesion,   220. 


Injections  for  neuralgia,  357. 
Injuries,  as  cause  of  antral  diseases, 
343. 

of  tongue,  154. 
Inspection,  84. 
Instruments,  321. 
Interdental  splints,  401. 
Intermaxillary  bone,  301. 
lodin,  in  bone  diseases,  175. 

in  surgery,   76. 

mouth  lesions  from,  135. 


Jacob's  ulcer,  281. 


K 

Koplik's  spots,  136. 


Lacerations,    55. 
Lanelongue's  operation,  330. 
Lathrop's  section  of   face,  337, 
Lead  poisoning,  134. 
Leontiasis  ossea,  197. 
Leprosy,  140. 
Leucoplakia,   152. 
Liehenization,  140. 
Ligatures,  78. 
Lingual  goiter,  155. 
Lip,  chancre  of,  222. 

double,  308. 
Lipoma,  241. 
Ludwig's  angina,  150. 
Lupus  eiythematosis,  140. 
Lupus  exedens,  281. 
Lupus  vulgaris,  210. 
Lymphangioma,   97,   245. 
Lymphatics,  diseases  of,  96. 

M 

Macrocheilia,  307. 
Macrogiossia,  246. 
Macula,  160. 
Malar  fracture,  415. 
Malignant  tumors,  275. 


464 


INDEX 


Mandible,  diseases  of,  179. 

dislocations  of,  422. 

fracture  of,  393. 
causes  of,  393. 
location  of,   393. 
repair  of,  395. 

multiple  cysts  of,  256. 

necrosis  of,   171. 

osteomyelitis  of,  182. 

periostitis  of,  181. 

tuberculosis  of,  196. 
Mania,  109. 

Maxilla,   diseases  of,   193. 
complications  in,  194. 

fracture  of,  408. 

sinus  of,  334. 

suppuration  of,  193. 

tabes  of,  196. 

tuberculosis  of,  196. 
Measles,  mouth  lesions  in,  134. 
Melanotic   sarcoma,   276. 
Mensuration,  84. 
Mercurial  necrosis,  107. 
Mercurial  looisoning,  134. 
Metallic  splints,  397. 
Microcheilia,   307. 
Microstoma,  307. 
Milium,  163. 

Miller's  study  of  bacteria,  104. 
Mitral  regurgitation,  89. 
Mitral  stenosis,  90. 
Mouth,  bacteria  of,  103,  123. 

chancre  of,   222. 

complex  structure  of,  101. 

development  of,  300. 

eczema  of,  138. 

effect  of  alcohol  on,  103. 

effect  of  tobacco   on,  103. 

epithelioma   of,   284. 

fulminating  ecthyma,  139. 

impetigo  contagiosa,  139. 

leprosy  of,  140. 

leucoplakia  of,  152. 

mucous  membrane  of,  101. 

pemphigus  of,  139. 

perleche,  140. 

psoriasis,  140. 


Mouth,  sarcoma  of,  278. 

scorbutic  lesions  of,  103. 

skin  lesions  of,  123. 

syphilis  of,  219. 

tuberculosis  of,  213. 

urticaria  of,  139. 
Mouth  gag,  318. 

Mouth  lesions,  differential  table  of, 
134. 

eczema,   136. 

from  iodin;   175. 

from   lead,   134. 

from  skin  diseases,  136. 

herjaes  zoster,  139. 

impetigo  contagiosa,  138. 

in  diphtheria,  133. 

in  measles,  133. 

in  rickets,  103. 

in  scarlatina,  133. 

in  typhoid  fever,  133. 

leprosy,  140. 

lichenization,  140. 

lupus  erythematosis,  140. 

of  skin,   138. 

pemphigus,   139. 

perleche,  140. 

pigmentation,  140. 

psoriasis,  140. 

rhinoscleroma,  140. 

scoi'butus,  103. 

seborrhea,  140. 

symptomatic,  133. 

Vincent's  angina,  141. 
Mouth  operations,  205. 
Mouth  retractor,  208. 
Muciparous  cysts,  243. 
Mucous  patches,  223. 
Multiple  cysts,  256. 
Muscles  of  soft  palate,  304. 
Muscular  spasms,  109. 
Mycosic  stomatitis,  129. 
Myeloid  epulis,  267. 


N 


Nasal  fracture,  413. 
Nasal  route,  351. 


INDEX 


465 


Naso-antral  fistula,   121. 
Naso-oral  fistula,  120. 
Necrosis,  11. 
alveolar,   180. 
chemical,  186. 
arsenic,  188. 
mercury,  187. 
phosphorus,  186. 
esanthematous,  192. 
of  mandible,  171. 
of  maxilla,  193. 
papilla  from,  203. 
varieties  of,  12. 
Neoplasms,  345. 
Netter's  study  of  bacteria,  104. 
Neuralgia,  from  reflex  neurosis,  108. 
of  fifth  nerve,  353. 
prognosis  of,  356. 
tic  douloureux,  356. 
treatment   of, .  avulsion,   360. 
injections,  356. 
medical,  353. 
neurectomy,  362. 
neurotomy,  362.  , 

operations,  359. 
Neurasthenia,  109. 
Neurectomy,  362. 
Neuroma,  242. 
Neurosis,   108. 
of  dentition,  102. 
of  face,  169. 
Neurotomy,  362. 
Noguchi  reaction,  38,  53. 
Non-specific  infections,  16. 
Nuhn,  glands  of,  371. 
cysts  of,   243. 


0 

Obstetric  fracture,  404. 
Obstruction  of  ducts,  370. 
Occlusion,  hysterical,  388. 
Odontomata,  249. 

cementous,   251. 

comi^osite,  254. 

epithelial,  250. 


Odontomata,  follicular,  250. 

radicular,  254. 
Operations,    for    alveolar    abscess, 

117. 
for  ankylosis,  379. 
for  antral  disease,  350. 
for  cleft  alveolus,  323. 
for  cleft  palate,  316. 

anesthetics  for,  317. 

Baldwin's,  325. 

Brophy's,   324. 

Ferguson's,  329. 

instruments  for,  321. 

Lanelongue's,  330. 

Roe's,  328. 

sutures  for,  325,  332. 

time  of,  316. 
for   dislocations,   423. 
for  fracture,  392. 

of  malar  bone,  415. 

of  mandible,  395. 

of  maxilla,  409. 

of  nasal  bones,   413. 

of  zygomatic  arch,  417. 
for  hare  lip,  bilateral,  313. 

dressings  for,  315. 

Malgaigne's,  311. 

Mirault-Langenbeck's,  312. 

Nekton's,  311. 

sutures  for,  315. 

unilateral,  313. 
for  neuralgia,  359. 
for  osteomyelitis,   183. 
for  ranula,  371. 
of  mouth,  205. 

retractor  for,  208. 
technique  of,  205. 
Oral  hygiene,  103. 
Oral  route,  350. 
Osseous  ankylosis,  380. 
Osteoma,  271. 
Osteoniyelitis,  acute,  173. 
bacterium  of,  171. 
chronic,  174. 
circumscribed,  173. 
differential  symptoms  of,  174. 
diffused,  173. 


466 


INDEX 


Osteomyelitis,  of  mandible,  182. 

of  maxilla,  193. 
Osteophytes,   271. 


Palpation,  84. 
Papilla,  203. 
Papilloma,  118. 

of  alveolus,  258. 

sinus  of,  118. 
Papular  acne,  161. 
Papule,  160. 

Paralysis  of  muscles,  170. 
Parasites  of  skin,  164. 
Patches,  mucous,  223. 
Pathology,  82. 
Pemphigus,  139. 
Percussion,  84. 
Periadenitis,  215. 
Pericarditis,  90. 
Periostitis,   acute  suppurative,  177. 

classification  of,  177. 

diffused,  50. 

of  mandible,  181. 

pathology  of,  178. 

post-febrile,  178. 

suppurative,  53. 

treatment  of,  178. 
Perleche,  140. 
Permanent  ankylosis,  378. 
Petechia,  160. 
Phenol,  76. 
Phlebitis,   93. 
Phosphorus  necrosis,  186. 
Pigmentation,  140. 
Pigments,  5. 
Pilocarpin,  134. 
Pneumococcus  of  Frankel,  104. 
Poisoned  wounds,  57. 
Poisoning,  by  arsenic,  112,  188. 

by  iodin,  136. 

by  lead,  134. 

by  mercury,  134. 

by  phosphorus,  186. 

by  pilocarpin,  134. 


Polypus  of  alveolus,  260. 

of  gum,  263. 
Post-febrile  periostitis,  178. 
Premaxillary  bone,  301. 
Primary  lesion,  40. 
Prognosis,  82. 
Proliferation,  8. 
Proteins,  4. 
Psoriasis,  140. 
Pulse,   91. 
Pus,  13. 

Pustule,  161.  .    ^ 

Pyemia,    20. 
Pyorrhea.  103. 

syphiliiic,  230. 

R 

Radicular  odontomata,  254. 

Ranula,   371. 

Reactions,   Noguchi,   38,   53. 

Wassermann,  39,  53. 
Reflex  neurosis,  108. 

muscular  spasms  from,  109. 

neuralgia  from,  110. 
Regeneration  of  bone,  199. 
Regurgitation,  89. 
Repair  of  bone,  in  dislocation,  176. 

in  fracture,  391. 
Retractor  for  mouth,  208. 
Rhinoscleroma,  140. 
Rickets,  103. 
Ringworm,  165. 
Risus  sardonicus,  170. 
Rodent's  ulcer,  281. 
Roe's  operation,  328. 
Rose  position,  320. 
Round-celled  sarcoma,  275. 


S 


Salivary  calculus,  368. 
Salivary  glands,  acute  affections  of, 
368.  ' 

congenital  absence  of,  364. 

diseases  of,  364. 

obstruction   of   ducts  of,  370. 


INDEX 


467 


Salivary  glands,  sarcoma  of,  374. 

suppuration  of,  365. 

tuberculosis  of,  375. 
Sapremia,  17. 
Sarcoma,  alveolar,  276. 

giant-celled,  275. 

melanotic,  276. 

of  mouth,  278. 

of  salivary  glands,  374. 

round-celled,  275. 

spindle-celled,   275. 

treatment  of,  279. 
Scabies,  165. 
Scalds,  60. 

treatment  of,  61. 
Scarlet  fever,  mouth  lesions  in,  134. 
Sclerosing  glossitis,  229. 
Scorbutus,  103. 
Scrofuloderma,  209. 
Sebaceous  cysts,  163. 
Sebaceous  glands,  161. 
Seborrhea,  140. 
Secondary  lesion,  223. 
Section  of  face,  Cryer's,  335. 

Lathrop's,   337. 
Self-infection,  104. 
Sepsis,  75. 
Septicemia,  18. 
Sequestrum,  172. 
Shock,  70. 

symptoms  of,  71. 

treatment  of,  71. 
Shriver's  statistics,  104. 
Sinus,  14. 

of  maxilla,  334. 

papilloma  with,  118. 
Skin  eruptions,  83. 
Skin  horns,  163. 
Skin  lesions,  in  dentition,  103. 

of  mouth,  138. 
Skin  parasites,  164. 
Soft  palate  muscles,  304. 
Spasms,   facial,   170. 

muscular,  109. 
Specific  infections,  23. 
Spindle-celled  sarcoma,  275. 
Spiroehnsta  pallida,  38. 


Splints,  interdental,  401. 

metallic,  397. 

wire,  395. 
Staphylococcus,  6. 
Staphyloplasty,  319. 
Stenosis  of  heart,  90. 
Stenson's  duct,  166. 

fistula  of,  167. 
Stomatitis,  aphthous,  129. 

cancrum  oris,  131. 

canker  sores,  125. 

catarrhal,  124. 

classification  of,  124. 

follicular,    128. 

gangrenous,  131. 

gonorrheal,  135. 

herpetic,  128. 

mercurial,  134. 

mycosic,  129. 

ulcerative,   125. 
Strawberry  tongue,  137. 
Streptococcus,   7. 
SupjDuration,    13. 

of  antrum,  345. 

of  maxilla,  193. 

of  salivary  glands,  365. 
Surgical  dressings,  77. 
Sutures,   78. 

in   cleft   palate,   325,   332. 

in  hare  lip,  315. 
Sycosis,   165. 
Symptoms,  82. 
Syphilides,  forms  of,  43. 
Syphilis,  bone  diseases  of,  47. 

cleft  palate  from,  232. 

diagnosis  of  chancre  in,  42. 

diffused  periostitis,  50. 

forms  of,  43. 

general  treatment  of,  51. 

gingi^dtis,  239. 

gummata,  228. 

hereditary,  234. 

inherited,  47. 

modes  of  contagion  of,  39. 

of  bones,  231. 

of  mouth,   219. 
forms  of,  220. 


468 


INDEX 


Syphilis,  of  mouth,  initial  lesion  of, 
220. 

secondary  lesion  of,  223. 

tertiai';v'  lesion  of,  227. 
of  soft  tissues,  234. 
of  tongue,  227. 
primary  lesion  of,  40. 
prognosis  of,  51. 
pyoiThea,  230. 
sclerosing  glossitis,  230. 
secondaiy  sjmiptoms  of,  43. 
"606"    (SalVarsan)   in,  53. 
stages  of,  39. 
suppurative  periostitis,  53. 
tertiary,  44. 


Tahes  dorsalis,  196. 
Technique,  in   operations,   205. 

in  X-ray,  425. 
Teeth,   as   cause   of   antral  disease, 
342. 

atrophy  of,  107. 

cysts  from  developed,  297. 

cysts  from  erupting,  298. 

eruption  of,  102. 

Hutchinson's,  106. 

impaction  of,  288. 

reflex  neuroses  from,  108. 

tumors  of,  248. 
Temporary  ankylosis,  377. 
Tertiary  lesions,  44,  227. 
Tetanus,  28. 
Thrush,   124. 
Tic  douloureux,  353. 
Tinea  sycosis,  165. 
Tinea  tiicophytina,  165. 
Tobacco,  effect  of,  103. 
Tongue,  S3. 

acquired  affections  of,  149. 

appearance  of,  146. 

chancre  of,  223. 

coatings  on,  146. 

congenital  defects  of,  147. 

epithelioma  of,  157. 

hypertrophy  of,  148. 


Tongue,  inflammation  of,  149. 

injuries  of,   154. 

leucoplakia  of,  152. 

Ludwig's  angina,  150. 

strawberry  tongue,  137. 

syphilis  of,  227. 

tongue  tie,  147. 

tuberculosis  of,  214. 

tumors  of,  156. 
Tongue  tie,  147. 
Tonsil,  chancre  of,  222. 

enlarged,  307. 

gumma  of,  228. 

inflammation  of,  137. 
Tonsillitis,  137. 

follicular,  135. 
Toxins,   5. 

Traumatism  in  necrosis,  181. 
Tricophytina,  165. 
Tuberculosis,  in  general,  etiology  of, 
32. 
pathology  of,  33. 
treatment  of,  34. 

of  face,  209. 

of  facial  bones,  196,   217. 

of  jaw,  209. 

of  maxilla,  196. 

of  mouth,  209. 

of  salivary  glands,   375. 

of  tongue,  214. 

recurring  ulcer  of,  213. 
Tuberculosis  cutis,  209. 
Tubular  carcinoma,  282. 
Tumors,  adenoma,  241. 

carcinoma,  279. 

cystic,   242. 

developmental,  248. 

endothelioma,  246. 

epithelial,  281. 

fibroma,  240. 

hemangioma,  245. 

in  general,  238. 

lipoma,   241. 

lymphangioma,  245. 

macroglossia,  246. 

malignant,  275. 

neuroma,  242. 


INDEX 


469 


Tumors,  odontomata,  249. 
of  teeth,  248. 
of  tongue,  156. 
papilloma,  258. 
polypus,  260. 
sarcoma,  275. 
vascular,  245. 

U 

Ulcer,  14. 

Jacob's,  281. 

rodent,  281. 
Ulcerating  gingivitis,  230, 
Ulcerative  stomatitis,  125. 
Uranoplasty,  319. 
Urticaria,  139. 


Vascular  tumors,  245. 
Verruca,  163. 
Vesicle,  161. 
Vincent's  angina,  141. 


W 

Warts,  163. 

Wassermann  reaction,  39,  53. 

Wharton's  duct,  concretions  in,  369. 

Wire  splints,  395. 

Wiring  of  bones,  397. 

Wounds,    54. 

contusions,  54. 

gunshot,  58. 

incised,  55. 

lacerations,  55. 

of  face,   167. 

poisoned,  57. 

punctured,  56. 


X-ray,  425. 


Zygomatic  arch,  417. 


(1) 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx, 

RD  523  IVI13  C.1 

Oral  surgery:  a  text  book  on  qenerasur 


2002099977 


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